referral protocol feb12 by HC120914114033

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                    REFERRAL PROTOCOL FOR ORAL SURGERY

These guidelines are intended to help PCTs and Primary Care Practitioners make an
informed decision when contemplating referring NHS Hampshire patients for minor oral
surgery to secondary care providers within Hampshire.

The responsibility for making an appropriate referral rests with the referring health
care professional. Referrers should use the appropriate form (please see attached).

A diagnostic quality radiograph that shows the tooth to be treated and supports
indication for referral should be provided for all referrals*. All radiographs should be
less than 6 months old, should be printed on photographic paper and will be returned to the
referring practitioners. *No radiographs are required for temporomandibular joint dysfunction
referrals.

Referrals are accepted for the following:

   1.   Oral medicine and pathology
   Abnormal areas in the mouth that are suspected of being oral
   cancer should be referred immediately on the Two Week Rule
   Head and Neck Referral forms. These are available from the
   Trusts directly and should be faxed to the appropriate Trust
   department.
   This service is provided at:
   Portsmouth Hospitals NHS Trust
   University Hospital Southampton NHS Foundation Trust
   Hampshire Hospitals NHS Foundation Trust (Basingstoke and Winchester)
   Royal Surrey County Hospital NHS Foundation Trust
   Frimley Park Hospital NHS Foundation Trust
   Salisbury NHS Foundation Trust


   2.       Orthognathic Surgery
           Congenital and Acquired Facial Deformity

   This service is provided at:
   Portsmouth Hospitals NHS Trust
   University Hospital Southampton NHS Foundation Trust
   Hampshire Hospitals NHS Foundation Trust (Basingstoke and Winchester)
   Royal Surrey County Hospital NHS Foundation Trust
   Salisbury NHS Foundation Trust


   3.       Trauma
           Fractures of cranio-facial skeleton, including dento-alveolar fractures.
           Facial lacerations

   This service is provided at:
                                          Feb12
Portsmouth Hospitals NHS Trust
University Hospital Southampton NHS Foundation Trust
Hampshire Hospitals NHS Foundation Trust (Basingstoke)
Royal Surrey County Hospital NHS Foundation Trust
Salisbury NHS Foundation Trust


4.       Surgical Extractions
        Symptomatic roots that require surgical removal or teeth/roots where there has
         already been an unsuccessful extraction.

        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 ankylosis.

        SEE REFERRAL CRITERIA FOR EXTRACTIONS

This service is provided at:
Practice in the Park, Havant (no GA or sedation)
Wessex Dental Specialist Centre, Fareham (no GA)
ISTC at Royal South Hampshire Hospital – over 16s only
Portsmouth Hospitals NHS Trust (no LA)
Hampshire Hospitals NHS Foundation Trust (Basingstoke and Winchester)
Royal Surrey County Hospital NHS Foundation Trust
Frimley Park Hospital NHS Foundation Trust
Salisbury NHS Foundation Trust


5.       Symptomatic Third Molars
     ALL referrals should follow NICE guidelines (http://publications.nice.org.uk/guidance-
     on-the-extraction-of-wisdom-teeth-ta1) and will only be accepted where access to
     secondary care skills and facilities are required such as:

        Complex anatomical considerations
        Pathology which may complicate the procedure
        Patient has medical complications which make management inappropriate in
         primary care.

This service is provided at:
Practice in the Park, Havant (no GA or sedation)
Wessex Dental Specialist Centre, Fareham (no GA)
ISTC at Royal South Hampshire Hospital – over 16s only
Portsmouth Hospitals NHS Trust (no LA)
Hampshire Hospitals NHS Foundation Trust (Basingstoke and Winchester)
Royal Surrey County Hospital NHS Foundation Trust
Frimley Park Hospital NHS Foundation Trust
Salisbury NHS Foundation Trust
                                           Feb12
6.       Dental Extractions       in   medically    compromised       patients   /   potential
         complications

     The vast majority of procedures should be undertaken in dental 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.

     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. The INR
     should be checked the day before or on the day of the extraction, usually at the GPs
     surgery and the procedure undertaken if the INR is less than 4.0. Bleeding should be
     controlled by local haemostatic measures.

        Refer patients on warfarin who require multiple extractions and those where the
         INR is >4.0.

Referrals can be made to Community Dental Services in line with their referral criteria.

Secondary care services are provided at:
Practice in the Park, Havant (no GA or sedation)
Wessex Dental Specialist Centre, Fareham (no GA)
ISTC at Royal South Hampshire Hospital – over 16s only
Portsmouth Hospitals NHS Trust (no LA)
Hampshire Hospitals NHS Foundation Trust (Basingstoke and Winchester)
Royal Surrey County Hospital NHS Foundation Trust
Frimley Park Hospital NHS Foundation Trust
Salisbury NHS Foundation Trust


7.       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.
     SEE REFERRAL CRITERIA FOR APICECTOMIES

This service is provided at:
Practice in the Park, Havant (no GA or sedation)
Wessex Dental Specialist Centre, Fareham (no GA)
ISTC at Royal South Hampshire Hospital – over 16s only
Portsmouth Hospitals NHS Trust (no LA)
Hampshire Hospitals NHS Foundation Trust (Basingstoke and Winchester)
Royal Surrey County Hospital NHS Foundation Trust
Frimley Park Hospital NHS Foundation Trust
Salisbury NHS Foundation Trust


8.        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
                                            Feb12
        has persistent TMJ Dysfunction problems or psychological problems. 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.

   This service is provided at:
   Portsmouth Hospitals NHS Trust
   University Hospital Southampton NHS Foundation Trust
   Hampshire Hospitals NHS Foundation Trust (Basingstoke and Winchester)
   Royal Surrey County Hospital NHS Foundation Trust
   Frimley Park Hospital NHS Foundation Trust
   Salisbury NHS Foundation Trust


   9.        Patients on Bisphosphonates
        If the patient has a medical condition where oral bisphosphonates are prescribed
        extractions can be carried out in primary care, after accessing specialist advice. All
        other patients should be referred to secondary care. If in doubt, please write for
        advice from the local Maxillofacial Department before making a referral.




Please note that the secondary care oral and maxillofacial service:

       Do not provide a routine dental service such as periodontal treatment,
        endodontic treatment.
       Do not accept referrals for routine extractions.

        Under the NHS Contract dental extractions (including multiple dental extractions) are
        a mandatory requirement and in circumstances where performers lack the expertise
        to competently remove teeth it is the responsibility of the contract holder to make
        alternative arrangements for the provision of care.

       Do not accept patients for economic reasons

								
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