Dental Institute Referral Protocols

Publication: 01/01/2011  
Next review: 15/01/2025  
Referral Guideline/Pathway
CURRENT 
ID: 2371 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Referral Guideline/Pathway is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Leeds Dental Institute Referral Protocols

  1. Introdiction
  2. Referral of patients
  3. Oral & Maxillofacial Surgery (OMFS)
  4. Oral Medicine
  5. Paediatric Dentistry
  6. Restorative Dentistry
  7. Orthodontics
  8. Dental and Maxillofacial Radiology

1. Introduction

The purpose of the Referral Protocols is to provide a clinical framework to support clinicians when referring their patients for advice, treatment planning and/or specialist treatment

The following pages give details for each of the specialist services commissioned by NHS England within the Leeds Dental Institute.

The majority of patients accepted for specialist care will be those requiring a hospital based consultant-led service.

The Leeds Dental Institute is also commissioned to provide education and training for undergraduate and postgraduate students as well as specialist training to consultant level. In order to support this aspect of work, patients with less complex needs will be considered for treatment by these training programmes.

For the majority of undergraduate clinics there is a separate recruitment website http://medhealth.leeds.ac.uk/info/1260/treatment HERE where potential patients can register. They will then be seen for assessment and if appropriate for undergraduate dental care, accepted for a single course of treatment.

For specialist and postgraduate training, recruitment of suitable patients will be   through consultant clinics

Suspected Oral Cancer Referrals

For patients with suspected oral cancer please refer using the Oral Cancer Referral Form (Appendix 1).

For referral of other urgent conditions, general dental practitioners (GDPs)  should please go to the main referral website (available at https://www.dental-referrals.org) and indicate that the referral is urgent and the reason why.

Urgent Advice

For dentists/doctors seeking urgent advice please phone (0113) 244 0111 and a message will be passed to the relevant specialist department and consultant as soon as possible. Please state the nature of the urgent problem and leave your telephone or secure email contact details to allow for a prompt response.

Back to top

2. Referral of patients

Accepting a referral

The clinician accepting a referral has a duty to fully understand the nature of the referral and to offer appropriate management or advice. It is therefore important that all the relevant details are provided by the referrer when referrals are made.

Whilst a patient is awaiting an appointment for consultation following referral, arrangements for emergency and routine treatment remain the responsibility of the referring clinician.

Inappropriate and incomplete referrals will be returned to the referrer by the Leeds Dental Institute and the reasons for non-acceptance explained.

Treatment, if appropriate, will only be undertaken for the condition in relation to the referral. Any outstanding primary care needs will be returned to the GDP for completion. Patients should clearly understand this before referral.

Back to top

3. Oral & Maxillofacial Surgery (OMFS)

Referrals from general dental practitioners should be sent electronically through the FDS system (https://www.dental-referrals.org) and from general medical practitioners through the e-Referral Service (formerly known as Choose & Book).

3.1 Management of Third Molars

Please see Yorkshire and Humber regional guidelines https://www.dental-referrals.org/

3.2 Other impacted or buried teeth

Please see Yorkshire and Humber regional guidelines https://www.dental-referrals.org/

3.3 Retained roots and failed extractions

Please see Yorkshire and Humber regional guidelines https://www.dental-referrals.org/

3.4 Management of dental cysts and odontogenic tumours

Radiographic evidence of intra-bony pathology should be referred to the OMFS service for further management.

3.5 Salivary gland disease

Patients with inflammatory or obstructive salivary gland disease should be referred to the OMFS service where surgical management is indicated.

3.6 Acute infections

Infectious conditions of the head and neck region which give rise to abnormal signs and symptoms should be referred to the OMFS service. Minor infections may be treated in accordance with ‘Adult Antimicrobial Prescribing in Primary Dental Care for General Dental Practitioners produced by the Faculty of General Dental Practitioners (UK) Royal College of Surgeons.

3.7 Temporomandibular Joint Disorder (TMJ Disorder)

The following Flow Chart is to aid practitioners with the management and referral of TMJ Disorder patients

3.8 The management of abnormal bony and soft tissue lesions

The OMFS service will receive referrals for soft tissue lesions of the skin in the head and neck region and the intra-oral environment. Where an abnormal lesion is suspected to be malignant, patients must be referred using the Oral Cancer Referral form (Appendix 1) for an urgent consultation.

Suspected cancer referrals are managed through the 2 week wait pathway.

Warning signs of oral cancer are:

  • Non-healing ulcer present for more than 2 weeks
  • A lump or thickening in the cheek or elsewhere in the mouth
  • A white or red patch on the gums, tonsils, or lining of the mouth
  • Persistent soreness of the throat or mouth
  • Difficulty chewing or swallowing
  • Numbness of the tongue or other area of the mouth
  • Swelling of the jaw that causes dentures to fit poorly or become uncomfortable
  • Loosening of the teeth or pain around the teeth or jaw
  • Voice changes
  • A lump or mass in the neck
  • Weight loss

Malignant lesions are often non painful at the time of presentation

3.9 Endodontic surgery

Please see Yorkshire and Humber regional guidelines https://www.dental-referrals.org/

Back to top

4. Oral Medicine

Referrals from general dental practitioners should be sent electronically through the FDS system (https://dental-referrals.org/ ) and from general medical practitioners through the eReferral Service (formerly known as Choose & Book).  An Advice & Guidance service is in the process of being established for Leeds GPs.

4.1 Breadth of service

Oral Medicine is the specialty of dentistry concerned with the oral health care of patients with chronic, recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and non-surgical management.

The key difference from Oral Surgery and Oral & Maxillofacial Surgery is that in Oral Medicine the emphasis is on conditions that are primarily managed medically without the need for surgery.

The scope of Oral Medicine practice includes disorders of:

  • Oral soft tissues (mucosa, tongue and lips)
  • Salivary glands
  • Neurological dysfunction including non-odontogenic (non-dental- related) pain

These disorders may reflect local oral problems or oral manifestations of systemic disease (e.g. gastrointestinal, rheumatological, dermatological, haematological, autoimmune, psychiatric or psychological disorders).

Oral Medicine acts as a focus for specialist interdisciplinary care of patients and there is close collaboration with other dental, medical and surgical specialties as required.

Many conditions that fall within the scope of Oral Medicine practice are chronic and may have a significant psychological, as well as physical impact on the patient’s quality of life.

Referrals are accepted for:

Changes to the oral mucosa, tongue or lips* including:

  • White lesions
  • Red lesions
  • Blistering conditions (vesicles or bullae)
  • Ulcerated lesions - persistent (lasting over 2 weeks) or recurrent
  • Pigmented lesions
  • Swelling (focal or more generalised)
  • Hypersensitivity reactions
  • Stomatitis and cheilitis (including infections)
  • Fibrosis

Changes to the saliva and salivary glands:

  • Sensation of oral dryness or decreased saliva volumes
  • Sensation of an overly wet mouth or increased saliva volumes
  • Salivary gland swelling*

Changes to neurological function* including:

  • Orofacial pain that is NOT due to dental disease such as caries or periodontal disease. e.g. burning mouth syndrome, trigeminal neuralgia & unexplained orofacial pain
  • Altered sensation or abnormal motor function of oral structures

*Where cancer is suspected, then referral should be made via the urgent “Fast-Track” 2 week cancer service via Oral & Maxillofacial Surgery.

Conditions that fall within the scope of Oral Medicine practice include:

  • Angioedema
  • Behçet’s disease
  • Chronic persistent facial pain
  • Dysaesthesias including burning mouth syndrome
  • Erythema multiforme
  • Graft versus Host Disease (GvHD)
  • Infections (viral, fungal or bacterial)
  • Lichen planus
  • Myofascial pain
  • Orofacial granulomatosis and oral Crohn’s Disease
  • Pemphigoid
  • Pemphigus
  • Recurrent aphthous stomatitis and other forms of recurrent oral  ulceration
  • Sialorrhoea
  • Sialosis
  • Sjögren’s syndrome
  • Trigeminal neuralgia

Back to top

5. Paediatric Dentistry

5.1 Referral Criteria

The specialty sees children and young people up to 15 years of age (i.e. up to their 15th Birthday) who present with oro-dental disease, where the management of their condition requires specialist/consultant assessment and/or treatment. All referrals should be made on the electronic referral form, and sent via the electronic referral management system [FDS]

The acceptance criteria for referred patients include those who are/have:

  • anxious or phobic who cannot be successfully treated in general dental practice:
    • where treatment has been tried and failed (in which case the treatment attempted and the problems encountered must be documented)
    • those for whom it is felt inappropriate to attempt definitive treatment in general practice e.g. under 3 years with rampant  early childhood caries,
      NB Where treatment has not been attempted, the referrer must explain why.
  • sustained complex dentoalveolar injuries which are beyond the scope of a general dental practitioner.
  • medically compromised whose delivery of care poses a risk to their general health or whose medical co-morbidity affects their dental condition.
  • inherited or acquired dental anomalies such as altered tooth structure, shape, size, form and number of teeth.
  • requiring surgical exposure and/or surgical removal of unerupted incisor teeth, including where this is associated with supernumerary teeth in the anterior maxilla. Patients requiring surgical exposure or removal of ectopic canine teeth should be referred to orthodontics or oral surgery.
  • requiring investigation of disorders of eruption and shedding of teeth.
  • additional needs or special care requirements who are not and could not be managed in general dental practice. Details of treatment attempted OR an explanation of why treatment has not been attempted should be included.

5.2 Children and young people attending with dental emergencies

Same day emergency referrals can be made to the Leeds Dental Institute under the following circumstances:

  • Acutely swollen face/systemically unwell
  • Dental trauma requiring urgent specialist management
  • Uncontrolled dental haemorrhage.

Where possible ALL emergency referrals must be preceded by a telephone call (0113 343 6229) to the department. A completed dental referral form including any appropriate radiographs (if available) should be sent with the patient and emailed to leedsth-tr.ldipaediatricreferralroutine@nhs.net so that it is available when the patient is seen. All emergency referrals will be triaged on arrival at LDI. Any that do not fulfill the above criteria will be returned to the referring practitioner without treatment being provided.

5.3 Children and young people requiring treatment under general anaesthesia

Dental Practitioners referring patients specifically for GA are subject to the   regulations laid down by the General Dental Council. In each case the referring practitioner should:

  • Give a clear written justification for the suggested use of general anaesthesia.
  • Provide details of any relevant medical history.
  • Explain to the patients and parents or carers the risks associated with general anaesthesia, and gain consent for the referral
  • Discuss alternative methods of providing the treatment.
  • Provide details of the treatment deemed to be required.
  • Retain a copy of their referral letter

It is important that the referral form contains information that confirms the above procedures have been completed, please use a separate sheet if needed. Failure to do so will result in the letter being returned to the referring practitioner. The final decision regarding treatment under GA or sedation will rest with the treating clinician.

5.4 Referral of children from outside Leeds

LDI will only accept referrals of children from out-with the Leeds area in the following circumstances:

  • From a local Consultant or Specialist in Paediatric Dentistry
  • Where a child requires multidisciplinary planning or tertiary care management which is not available in the child’s local area.
  • When in doubt, practitioners should refer to their local specialist provider (in most cases the Community Dental Services) in the first instance.
  • Referrals for children not fulfilling one of the two criteria above and resident outside the Leeds area where suitable local specialist services exist (e.g. via the local Community Dental Service), will not be accepted.

Referral for children from out-with the Leeds area should be made on the electronic referral form, or as individual letters, and emailed to leedsth-tr.ldipaediatricreferralroutine@nhs.net giving details of why the child needs to be seen at LDI.

Back to top

6. Restorative Dentistry

The Restorative Dentistry Service at the LDI provides specialist treatment as well as a diagnostic and treatment planning service to referring practitioners. The intention of all consultants in restorative dentistry is to work in partnership with the referring dentist responsible for the routine dental care of the patient. This means that the patient may be referred back to the referring dentist for specific items of treatment or all of the recommended treatment with a detailed treatment plan where indicated.

The following general categories of patients are accepted for treatment within the relevant Restorative sub-specialty:

  • Oncology Patients: intraoral cancer resections, obturators and post radiotherapy management.
  • Developmental defects: cleft lip and palate, severe hypodontia, joint orthognathic and/or orthodontic cases and amelogenesis, dentinogenesis imperfect cases.
  • Trauma: severe trauma (such as seen in patients following road traffic accidents) involving significant damage to the dentoalveolar complex.
  • Severely medically compromised, e.g. patients with severe bleeding disorders, immunocompromised and post organ transplantation.

Please complete the General Restorative Referral Form (Appendix 2) for those referrals that do not fit into any of the categories below and email to leedsth-tr.restorativereferral@nhs.net .

6.1 Periodontics

Referrals for periodontics must be made using the Specialist Periodontal Referral Form (Appendix 3) and emailed to leedsth-tr.restorativereferral@nhs.net .

Leeds Dental Institute provides:

  • An assessment and advice service for periodontal patients
  • Secondary care treatment by staff members as detailed in the criteria below
  • Basic periodontal treatment by undergraduate dental students/ student hygiene and therapists*

Patients accepted for secondary care assessment (not necessarily treatment) include
those with:

  • Severe periodontal disease (BPE scores of 4), where primary care treatment has been unsuccessful.
  • Aggressive disease (Grade C disease), judged by severity of periodontal destruction relative to age or rate of periodontal breakdown.
  • A need for surgical management (e.g. Mucogingival procedures for recession defects, open flap debridement, regenerative procedures, crown lengthening)
  • A risk of severe periodontal disease due to a medical condition (e.g. poorly controlled diabetes, drug induced gingival hyperplasia)
  • A risk of complications from periodontal treatment (e.g. bleeding disorders, immunocompromised)
  • A requirement for complex restorative planning in a patient with periodontal disease.

*A certain number of cases are required each year after which the waiting list may be closed Information about this pathway is available on the University of Leeds website: http://medhealth.leeds.ac.uk/info/1260/treatment. There may be a delay in treatment commencing.

Please note that even if treatment in secondary care is anticipated, initial therapy
should normally be carried out in the primary care setting, including:

  • Oral health education: tooth brushing instruction/ interdental cleaning instruction.
  • Smoking cessation advice (if appropriate).
  • Full mouth supra and subgingival debridement, carried out with local anaesthetic where required
  • Periodontal charts recorded prior to and 2-3 months after completion of the above.

All referrals should include the following:

  • Periodontal Referral Form (*please ensure that you use the current referral form – contact the LDI via email: leedsth-tr.restorativereferral@nhs.net)
  • Basic Periodontal Examination (BPE) scores
  • Periodontal charts including probing depths, mobility and plaque scores (pre and post treatment, taken within 12 months of referral)
  • Confirmation that appropriate primary care, as detailed above, has been completed
  • Radiographs of diagnostic quality

Referrals not meeting these criteria will be returned with a request for further
information.

Discharge procedures following periodontal treatment:

  • Following treatment, patients are referred back to their practitioner with pre- and post-treatment charts and recommendations for a life-long supportive periodontal therapy programme. This emphasises the role of patients and primary care provider in disease management. Supportive care is essential for maintaining periodontal stability.
  • There will be a percentage of patients who fail to adhere to the proposed treatment plan. These patients will be discharged with a plan for supportive care within the primary care sector, accepting that a gradual deterioration is likely.

6.2 Prosthodontics (Fixed and removable complete and partial dentures)

Referrals for removable prosthodontics must be made using the Removable Prosthodontics Referral Form (Appendix 4) and emailed to leedsth-tr.restorativereferral@nhs.net

A limited number of patients may be accepted for specialist treatment, postgraduate training
or undergraduate care, but only after the initial treatment by the referring practitioner has not been successful.

The following criteria should be met prior to referral:

  • Patients should have good oral / denture hygiene
  • Active caries, lost or fractured restorations should have been appropriately managed
  • Significant periodontal disease should be appropriately managed

Otherwise, the patient will usually be discharged back to the referring dentist for provision of this treatment.

For the majority of removable prosthetics cases it is expected that the General Dental
Practitioner has attempted treatment prior to referral. Where dentures are obviously ill-fitting, the patient should have been provided with new dentures. They should only be referred if they continue to experience difficulties (unless reasons are given as to why this is inappropriate e.g. obturator construction).

If patients are offered treatment within the Leeds Dental Institute, their ongoing routine dental care and maintenance must still be provided within General Dental Practice. Patients should therefore continue to be seen for recalls and any routine treatment required whilst also undergoing treatment in the LDI. Patients will then be discharged back to their General Dental Practitioner following completion of treatment.

6.3 Endodontics

Referrals for endodontics must be made using the Specialist Endodontic Referral Form
(Appendix 5)
and emailed to leedsth-tr.restorativereferral@nhs.net .

The Leeds Dental Institute provides a diagnostic, treatment planning and advice service for patients with endodontic problems and specialist treatment when indicated

ENDODONTIC REFERRAL GUIDELINES

In addition to the completion of the standard dental and Specialist Endodontic Referral Forms, referrals must include:

  • A periapical radiograph of diagnostic value
  • Confirmation that the tooth has a good periodontal and restorative status
  • An important reason to retain a tooth

Referrals will be returned if:

  • They are illegible
  • The form is incomplete or does not meet the acceptance criteria detailed below

Criteria for acceptance for treatment:

  • For advice only on endodontic problems and/or a pain diagnosis
  • Root canals with anatomical complexities e.g. curvatures of >45o
  • Root canals that are NOT considered negotiable from radiographic or clinical evidence through their entire length. This is on the understanding that patients will be returned to you for completion of root canal treatment and final restoration where indicated.
  • For endodontic complications of trauma e.g. Tooth with open apices, root fractures etc.
  • Periradicular surgery of failed RCT in the presence of adequate conventional obturation
  • Pathological resorption
  • Feasible removal of fractured instruments and intra-radicular posts in teeth of reasonable prognosis
  • Root perforations
  • Conventional re-treatment of failed root canal treatment

Patients will not be offered treatment if:

  • They are not registered with a dentist
  • They have poor oral hygiene, active caries and/or periodontal disease which is unmanaged
  • The referral has been made on the patient’s inability/unwillingness to pay NHS charges
  • The prognosis for the tooth is considered poor
  • They require sedation or GA for routine dental treatment
  • The tooth is a molar unless it is of strategic value to the overall treatment plan

6.4 Tooth wear

Referrals for tooth wear must be made using the Tooth Wear Referral form (Appendix 6) and emailed to leedsth-tr.restorativereferral@nhs.net .

A full diagnostic and advisory service is available. It is helpful if serial models or photographs to show the rapidity of the tooth wear where appropriate accompany referrals. In younger patients it is expected that a full dietary analysis will have been undertaken and appropriate advice given prior to referral. This might include the prescription of a fluoride mouth rinse where indicated.

Patients will be directed back to their dentist for items of treatment that can reasonably be carried out within primary dental care.

Please note that the referral form has guidance on treatment that would be expected to be carried out in primary care prior to referral. Referrals may not be accepted if such interventions have not been undertaken.

6.5 Dental Implants

Referrals for dental implants must be made using the Dental Implant Referral form (Appendix 7) and emailed to leedsth-tr.restorativereferral@nhs.net .

The criteria for implant placement available on the NHS are strict and the Leeds Dental Institute is only able to provide implant-based treatment to a limited selection of cases, which include:

  • Developmental disorder - malformed, missing or ectopic teeth (e.g. hypodontia, cleft palate, amelogenesis or dentinogenesis imperfecta)
  • Trauma -teeth lost or of poor prognosis subsequent to trauma
  • Head and neck cancer - previous surgery and/or radiotherapy
  • Severe denture intolerance - despite construction of technically acceptable dentures e.g. edentulous patients with severe ridge resorption, neuromuscular disorders etc

Please note that belonging to one of these categories does not guarantee that implant based treatment can be offered at the Leeds Dental Institute. In most cases, alternative treatment options must have been attempted prior to consideration of implant placement (unless that is clearly not appropriate).

Patients will not be offered treatment if:

  • They are not registered with a dentist
  • They have poor oral hygiene, active caries and/or active periodontal disease
  • They are a current smoker

The Leeds Dental Institute is not normally able to offer treatment in the following instances:

  • Completion of implant treatment commenced outside of the NHS
  • Management of failing implants or implant-retained prostheses provided outside of the NHS
  • Maintenance of implants or restorations provided outside of the NHS

However, patients may be given special consideration if they are in one of the high priority categories listed above.

If patients are offered implant-based treatment, their on-going routine dental care and maintenance must still be provided within General Dental Practice. Patients should therefore continue to be seen for recalls and any routine treatment required whilst also undergoing treatment in the Leeds Dental Institute.

Following a review period after completion of implant-based treatment, patients will usually be discharged from the Leeds Dental Institute for maintenance in General Dental Practice.

Back to top

7. Orthodontics

7.1 Referral criterion

The hospital orthodontics service at Leeds Dental Institute (LDI) will provide treatment at mainly procedure Level 3b but also some Level 3a or 2 “with modifying factors” – as defined in the NHS England “Commissioning Guide for Orthodontics” (September 2015) – see www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/09/guid-comms-orthodontics.pdf for further details.

All referring clinicians should first register with the secure on-line dental referral management system at www.dental-referrals.org.  Then you must complete the on-line Specialist Orthodontic Referral form (Appendix 8). Please include any relevant current x-rays and ensure that they are marked correctly and securely attached. Study models must be packed separately and securely in order to prevent damage in transit. They should be sent to the: Orthodontic Department, Leeds Dental Institute, Clarendon Way, Leeds, LS2 9LU.

Patients should only be referred if they fulfill the criteria below:

  • The patient should be referred at the appropriate dental age. Normally patients are ready for treatment when most of the permanent dentition has erupted. Generally, two premolars or a premolar and a canine should be erupted in all four quadrants. Exceptions to this rule are those children with severe malocclusions or where possible interceptive treatment, such as pushing an incisor over the bite or delayed tooth eruption or developing Class III, may require the child to be seen at a younger age (8-10 years). Patients with non- routine pathology such as root resorption or cysts should also be  referred early.
  • The patient’s dental care must be adequate. Excellent oral hygiene i.e. no active gum disease or periodontal pockets, no bleeding on probing and no untreated caries. Careful dietary control is essential before orthodontic appliances can be placed in the mouth. If these fundamental criteria are not met then significant periodontal and tooth damage can occur during orthodontic treatment.
  • Patient motivation and “want” for treatment. The probability of the patient having to wear either a removable or fixed brace to correct their problem should be fully discussed with the patient prior to their referral. There is little point referring a patient who is not prepared to commit to wearing an orthodontic appliance for up to 3 years.

7.2 Occlusal Indices

Orthodontics has a well-developed series of national and international Occlusal Indices which can be used to assess the treatment need of an individual patient. The index most often used to assess this is the Index of Orthodontic Treatment Need – IOTN.

The index has two components:

  • Aesthetic Component (AC)
  • Dental Health Component (DHC)

IOTN index.

NHS England only commissions services to treat child patients in IOTN 3.6 = DHC 3 and AC 6 and above for orthodontic treatment. The LDI accepts very few IOTN 3 grades and only a limited number of grade 4d are accepted for teaching or training purposes.

The detailed IOTN categories are as follows:

IOTN Grade 3 – Moderate treatment need

  1. Increased overjet 3.5 mm but ≤6 mm with incompetent lips.
  2. Reverse overjet greater than 1 mm but ≤3.5 mm
  3. Anterior or posterior crossbites with 1 mm but ≤2 mm discrepancy between retruded contact position and intercuspal position.
  4. Displacement of teeth 2 mm but to ≤4 mm.
  5. Lateral or anterior open bite greater than 2 mm but ≤4 mm.
  6. Increased and complete overbite without gingival or palatal trauma.

IOTN Grade 4 – Great treatment need

  1. less extensive hypodontia requiring prerestorative orthodontics or orthodontic space closure to obviate the need for prosthesis
  2. Increased overjet 6 mm but ≤9 mm
  3. Reverse overjet 3.5 mm with no masticatory or speech difficulties
  4. Anterior or posterior crossbites with 2 mm discrepancy between retruded contact position and intercuspal position
  5. Severe displacements of teeth 4 mm
  6. Extreme lateral or anterior open bites 4 mm
  7. increased and complete overbite with gingival or palatal trauma
  8. Posterior lingual crossbite with no functional Occlusal contact in one or both buccal segments
  9. Reverse overjet greater than 1 mm but less than or equal to 3.5mm with recorded masticatory and speech difficulties
  10. Partially erupted teeth, tipped and impacted against adjacent teeth
  11. Supplemental teeth

IOTN Grade 5 – Very great treatment need

  1. Increased overjet 9 mm
  2. Extensive hypodontia with restorative implications (more than one tooth missing in any quadrant) requiring pre-restorative orthodontics
  3. Impeded eruption of teeth (with the exception of third molars) due to crowding, displacement, the presence of supernumerary teeth, retained deciduous teeth and any pathological cause
  4. Reverse overjet greater than 3.5 mm with reported masticatory and speech difficulties
  5. Defects of cleft lip and palate
  6. Submerged deciduous teeth

7.3 Details of Aesthetic component

Grade 1 = most aesthetic arrangement of the dentition

Grade 1-4 = little or no treatment required

Grade 5-7 = moderate or borderline treatment required

Grade 8-10 = treatment required

Grade 10 = least aesthetic arrangement of the dentition

Please note:

Referrals will not be accepted unless there is a reasonable estimation of the IOTN DHC and AC grades on the referral proforma.

Please always complete the online orthodontic referral form as fully and as accurately as possible when referring   orthodontic patients.

Back to top

8. Dental and Maxillofacial Radiology

Referrals for radiographs for Cone Beam CT scans and second opinions should be requested using the Referral to Leeds Dental Institute Radiology Department for Imaging & Second Opinions Referral Form  (Appendix 9) and emailed to leedsth-tr.RadiologyLDI@nhs.net . Images will be returned on an encrypted CD and a radiographic report will be provided in all cases.

NOTE:  if patients are being treated in General Dental or Specialist Practice as a private patient they will only be accepted for imaging on a private basis.
General Dental and Specialist Dental Practitioners may refer both private and NHS patients to the Dental Radiology Department for the following investigations:

  • Panoramic radiography (General and Specialist Dental Practitioners)
  • Cone Beam CT (Specialist Dental Practitioners only)
  • Second opinions on radiographs can also be sought (General and Specialist Dental Practitioners)

Under the Ionising Radiation Medical Exposure Regulations 2017 (IRMER 17) referrals will only be accepted if sufficient clinical information is provided to allow the radiographic investigation to be justified.

Panoramic radiography should be considered in the following clinical situations:

  • Bony lesion or unerupted tooth not completely demonstrated on intra-oral radiographs
  • Grossly neglected dentition for which multiple extractions are required*
  • For the assessment of third molars prior to planned surgical intervention
  • As part of an orthodontic assessment to determine the state of the dentition and the presence or absence of teeth
  • Assessment of periapical status in the presence of multiple heavily restored and root-filled teeth
  • Strong gag reflex preventing acquisition of indicated intraoral films. The indication of the intraorals should be provided.*
  • Staging and grading of periodontal disease*

 Panoramic radiography for visualising the TMJs can be considered in the following circumstances:

  • Recent evidence of progressive pathology in the temporomandibular joints: recent trauma; change in occlusion; mandibular shift; sensory or motor alterations; change in range of movement. However, panoramic radiography of the TMJs will only be undertaken following assessment by a specialist.

*Examples of requests that will be rejected are:

  • ‘Panoramic for caries and periodontal disease diagnosis.’
  • ‘Panoramic as unable to obtain intraorals due to a strong gag reflex.’
  • ‘General dental assessment’

*Examples of requests that will be accepted are:

  • ‘Panoramic requested due to multiple carious teeth requiring extraction and periodontal disease – BPE scores of Code 4 in 4 sextants.’
  • ‘Periodontal disease –BPE scores of Code 4. Panoramic requested as unable to obtain intra-orals due to a strong gag reflex.’ NB: Due to the greater resolution intra-orals attempts will be made to obtain these where possible.

CBCT could be considered in the following clinical scenarios where the clinical question cannot be answered with plain films:

  • Implant planning,
  • Jaw lesions*
  • Assessment of unerupted/ectopic teeth
  • Assessment of symptomatic wisdom teeth
  • Dento-alveolar and facial trauma
  • Surgical planning
  • Foreign bodies/displaced roots involving the maxillary sinus

*CBCT should not be used where soft tissue assessment is required or as a primary modality where malignancy is suspected.

Second opinions

  • The Referral Form (Appendix 9) should be completed for all requests for second opinions.
  • For referrals including digital radiographs, the Referral Form and digital radiographs (attached as JPEG attachments) should be emailed to leedsth-tr.RadiologyLDI@nhs.net.
  • For referrals including conventional radiographs, the Referral Form and conventional radiographs should be sent to Radiology Department, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU. All radiographs will be returned.
  • In all cases, it is the Referrer’s responsibility to ensure that the correct images are matched with the correct patient.

NOTE: second opinions on CBCTs cannot be provided. If imaging has been obtained as part of a private course of treatment and a second opinion is required, this will incur a cost.

Further information is available from Selection Criteria for Dental Radiography 3rd Edition 2013 - Editor K Horner, K A Eaton, Faculty of General Dental Practice (UK) for guidance (available from the FGDP), Implementing the 2017 Classification of Periodontal Diseases to reach a Diagnosis in Clinical Practice(www.bsperio.org.uk) or by contacting the Radiology Department LDI (0113) 343 6213.

Provenance

Record: 2371
Objective:

Provide a clinical framework to support the practitioner when referring their patients who are registered with an NHS Leeds GP.

Clinical condition:

dental, oral and maxillofacial conditions

Target patient group:
Target professional group(s): Primary Care Doctors
Dental Staff
Adapted from:

Evidence base

Not supplied

Document history

LHP version 4.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.