These pages are for the benefit of our primary care colleagues both dental and medical.

Referral guidelines & referral profoma

Surgical Endodontics (Apicectomy)

We are happy to accept referrals for consideration of peri-radicular surgery / apicectomy.

We would however respectfully request that the following be noted.

1) Location: Ordinarily we would only consider apicecting the upper anterior teeth (i.e. upper central & lateral incisors and the upper canine teeth). Due to a number of anatomical reasons, apical surgery on other teeth is difficult, caries several varying risks and is likely to be associated with poor outcomes.

2) Repeat orthograde root canal treatment. Existing guidance (see below) suggests that efforts should be made to repeat the orthograde root canal treatment / filling where at all possible before considering apical surgery - even if further primary care cost is involved. It would be inappropriate to carry out apical surgery in secondary care because there is 'no charge', over repeat RCT in primary care (with charge).

3) Radiographs. Referrals should be accompanied by an up-to-date, good quality, appropriately-sized radiograph as per our radiology guidelines mentioned elsewhere in this section.

We will consider apical surgery on, say, an upper first premolar if this should be part of an otherwise satisfactory bridge but the prognosis will be poor given the two-rooted nature of these teeth.

We will offer apical surgery under local anaesthetic and / or IV sedation.

The current guidance for Surgical Endodontics is as follows

Transfer of Radiographs

We can provide a more efficient service if all relevant radiographs are sent with the letter of referral. We realise systems differ and that not all practices have access to OPT machines.

The attached form can be completed and sent direct to Radiology for those without OPT machines

Sending existing x-rays with referrals (including digital images)

We strongly encourage (in accordance with GDC guidelines) the sending of relevant radiographs with a patient referral. This significantly improves the running of our clinics and results in less delay for the patient. These do, however, need to be of a minimum quality.

Traditional "wet" film radiographs

We would request that

  • All the tooth/teeth in question be imaged completely, ideally with at least 3mm beyond the apex.
  • The film be generated with correct x-ray penetration to ensure a good quality film.
  • The film be processed and washed properly.

Digital images

Printed images - the best results are achieved when:

  • Good quality photo paper is used
  • The image is printed as close to life-size as possible (i.e. please avoid "blowing-up" an intra-oral view to A4 size)
  • The image is printed at 'best' resolution / dpi with care taken to ensure good contrast of the image befor eprinting

CD images

We realise many practices now have digital x-ray systems and view the images on monitors (rather than traditional wet films).

We are happy to accept images on a CD providing the following criteria are met (to ensure compatability with our system & data protection laws)

  • The images must be in a DICOM format
  • Each image must contain at least 3 points of identification. Forename, family name, Date of birth & NHS number (if known)
  • The images must be encrypted if being sent through the post. The password should be sent under separate cover detailing which patient it refers to.

CDs received that do not comply with the above will be rejected with the entire referral.

Electronic transfer of images

Unfortunately we are unable to accept images by email at the current time due to data security reasons.

One-stop dento-alveolar & intra-oral soft tissue treatment

We would like, where possible, to carry out this treatment in one sitting (i.e combine the out-patient appointment and the surgical treatment). We are actively identifying patients who may be suitable and arranging for one-stop treatment when they so wish.

For this to work we have to have a good quality, contemporaneous radiograph and a full medical history at the time of referral. Please help us to provide this efficient service (that patients seem to like) by including this information whenever possible.

Advice for dental practitioners regarding Medication-Related Osteo-Necrosis of the Jaws (MRONJ)

Nomenclature is changing as it appears that it is not only bisphosphonates that are implicated in the pathogenesis of this condition. Other anti-resorptive medicines may also be implicated.

Bisphosphonate-Related ONJ = Medication-Related ONJ = Anti-resorptive-Related ONJ = Medication-Induced ONJ

Evidence has emerged that patients taking bisphosphonate and other anti-resorptive drugs are at risk of developing MRONJ. This can occur spontaneously but more commonly following dental extractions or oral bone surgery.

Risk

Anti-resorptive medicines (including bisphosphonates) are widely prescribed in oral formulation for osteoporosis management. Patients in this category are generally regarded as being at a low-risk of MRONJ developing (incidence estimated at 1 in 10,000 to 1 in 100,000).

Bisphosphonates are also prescribed by Haematology physicians for management of skeletal effects of malignancy (multiple myeloma, bony metastatic lesions and hypercalcaemia of malignancy. Patients in this category are generally regarded as being at high-risk of MRONJ developing (incidence estimated at 1 in 10 to 1 in 100)

These risks may be increased by other factors such as steroid therapy, diabetes, chemo & radiotherapy and alcohol and tobacco use.

The risk increases with the length of time patients have been taking the drugs, with 3 years seen as a threshold point for an increased likelihood of adverse effects.

Guidelines (reference: NHS Tayside BRONJ guidance letter)

1) Dental practitioners should ask about current or past use of bisphosphonates / anti-resorptives when taking a drug history.

2) Prior to commencement of bisphosphonate / anti-resorptive therapy, prescribers should advise patients of the risks of MRONJ developing. Patients should be advised to see a dental professional promptly for assessment. All necessary dental treatment should be completed as soon as possible prioritising extractions and sub-gingival scaling. Treatment strategies and preventive advice should be designed to to minimise the need for future extractions. Poorly-fitting dentures should be replaced.

3) During bisphosphonate / anti-resorptive therapy. Patients need regular dental care and careful attention to oral hygiene and diet. Avoid extractions if at all possible. Consider RCT and crown amputation.

4) If extractions are required, fully advise the patient of the risk of MRONJ developing and obtain written consent (and provide written information - see below). Low-risk extractions can usually be performed in primary care (see following documentation). In high-risk cases and those where difficulties are anticipated, referred to oral & maxillofacial surgery would be appropriate. There is little evidence that pre-and post operative anti-biotics are effective in preventing MRONJ, although some experts have recommended their use based on risk hierarchy. Chlorhexidine mouthwash should be used twice daily during the week leading-up to the extractions and for 2 months after. The patient should be reviewed until healing has completed. Extractions should be carried out in stages allowing a 2 month disease-free follow-up period before proceeding to other parts of the mouth.

5) The typical presenting features of MRONJ are: delayed healing of socket, pain, swelling, loosening of teeth, exposed bone, paraesthesia. purulent discharge via intra-oral or extra-oral sinus. If any of these signs or symptoms then prompt referral to the OMFS department is advised.

Guidance documents

Scottish Dental Clinical Effectiveness Programme: Oral health management of patients prescribed bisphosphonates - Dental clinical guidance

Scottish Dental Clinical Effectiveness Programme: Advice letter for patients prescribed bisphosphonates

Local documents

Haematology referral letter for dental assessment

Management of Temporo-mandibular Disorders (TMDs) by Primary Care Dental & Medical Practitioners

We receive a large number of referrals for the assessment of temporo-mandibular disorders (TMDs). There is good, recent evidence that a large proportion of these patients can be managed in the primary care dental & medical setting.

TMDs are musculo-skeletal disorders and represent the most common cause of chronic pain in the orofacial region.

There are three main groups of TM problems.

1) Temporo-mandibular myofascial pain dysfunction (TMD / MFPDS). This is essentially an acute or chronic soft tissue pain problem.

2) Temporo-mandibular joint articular surface arthritis. Essentially osteo or less commonly rheumatoid arthritis of the condylar head of the mandible or glenoid fossa / articular eminence system.

3) Internal derangement of the cartilage disc and associated muscular groups.

In addition there may be instances when more than one of the above is present in the same patient.

We do appreciate that the assessment, diagnosis and management of patients with these conditions is notoriously challenging. The following guidance has, for the first time, provided comprehensive information, with input from many different speciality groups from restorative dentistry, pain managament and oral / maxillofacial surgery to name but a few.

This document contains an overview of the current treatment options available to patients who have temporo-mandibular disorders (TMDs). The authors are the UK Specialist Interest Group in Oro-facial Pain and TMDs. It is published by the Faculty of Dental Surgery, Royal College of Surgeons (Eng).

Guidelines for the management of TMDs by Primary Care Medical & Dental Practitioners

Gloucestershire Hospitals OMFS Dept. Patient Information Leaflet for TMD problems

Management of Dental Patients taking Anticoagulants or Antiplatelet Drugs

An increasing number of patients are being prescribed anticoagulants or antiplatelet drugs for prevention of stroke or thrombo-embolic events.

Essentially the drugs are divided into two main groups

Anticoagulants

  • Warfarin (& other vitamin K antagonists)
  • Novel or new oral anticoagulants - NOACs (e.g. dabigatran, rivaroxaban & apixaban)

Antiplatelets

  • Aspirin, clopidogrel & prasugrel

The advice as how to best manage these patients (especially those on Novel oral anticoagulants) is still evolving and depends on the drug that is being taken, any co-morbidities / medicines and the treatment proposed. Strong evidence is lacking and is currently based around expert opinion, consensus and existing guidance / experience.

The OMFS department does NOT have a local guideline / policy regarding this but the interested reader is directed to the following national guidance & articles.

Scottish Dental Clinical Effectiveness Programme - "Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs" - published August 2015

NICE Clinical Knowledge Summary

Curtin C, Hayes JM, Hayes SJ. Dental implications of new oral anticoagulants for atrial fibrillation. Dental Update. 2014;41:526-531

BEST CARE FOR EVERYONE