Referring to our dental services

To refer to this service please complete a oral and maxillofacial referral form [docx] 124KB and send it to the oral surgery team.

Please note that we no longer accept postal or fax referrals. All referral forms must be electronically completed and hand written forms will be returned.

• Referrals will be accepted for advice, treatment planning and, for those patients meeting our acceptance criteria, they will be accepted for comprehensive treatment.
• Patients who are not dentally fit will not be accepted and should not be referred in the first instance unless they are fit for treatment.
• Those patients who are accepted for treatment will be expected to continue to be registered with a general dental practitioner.
• Patients can only be accepted where we have capacity to care for them.
• NHS England is committed to monitoring for the quality of referrals to secondary care.

Level of complexity

Level 1 complexity	Procedures/conditions to be performed or managed by a clinician commensurate with a level of competence as defined by the Curriculum for Dental Foundation Training or its equivalent. This is the minimum that a commissioner would expect to be delivered in a primary care contract.
Level 2 complexity	Procedures/conditions to be performed or managed by a clinician with enhanced skills, and experience who may or may not be on a specialist list. This care may require additional equipment or environment standards but can usually be provided in a primary care setting.
Level 3a complexity	Procedures/conditions to be performed or managed by a clinician recognised as a specialist at the GDC defined criteria and on a specialist list; OR by a consultant.
Level 3b complexity	Procedures/conditions to be performed or managed by a clinician recognised as a consultant in the relevant specialty, who has received additional training which enables them to deliver more complex care, lead MDTs, MCNs and deliver specialist training. The consultant team may include trainees and SAS grades. Oral Surgery to also be delivered by Consultants in Oral and Maxillofacial Surgery who have the necessary competencies.

Level 1 procedures and conditions

• Extraction of erupted tooth/teeth including erupted uncomplicated third molars
• Effective management, including assessment for referral unerupted, impacted, ectopic and supernumerary teeth
• Extraction as appropriate of buried roots (whether fractured during extraction or retained root fragments),
• Understanding and assistance in the investigation, diagnosis and effective management of oral mucosal disease
• Early referral of patients (using 2-week pathway) with possible pre-malignant or malignant lesions
• Management of dental trauma including re-implantation of avulsed tooth/teeth
• Management of haemorrhage following tooth/teeth extraction
• Diagnosis and treatment of localised odontogenic infections and post-operative surgical complications with the appropriate therapeutic agents
• Diagnosis and referral patients with major odontogenic infections with the appropriate degree of urgency.
• Recognition of disorders in patients with craniofacial pain including initial management of temporomandibular disorders and identification of those patients that require specialised management

Level 2 procedures and conditions

• Surgical removal of uncomplicated third molars involving bone removal
• Surgical removal of buried roots and fractured or residual root fragments
• Management and surgical removal of uncomplicated ectopic teeth (including supernumerary teeth)
• Management and surgical exposure of teeth to include bonding of orthodontic bracket or chain
• Surgical endodontics
• Minor soft tissue surgery to remove apparent non-suspicious lesions with appropriate histopathological assessment and diagnosis.eg: Fibroepithelial polyp & mucocele
• Failed extraction (attempted extraction not completed)
• Level 3 procedures and conditions
• Procedures involving soft/hard tissues where there is an increased risk of complications (such as nerve damage, displacement of fragments into the maxillary antrum and fracture of the mandible)
• Management and/or treatment of salivary gland disease
• Surgical removal of tooth/teeth/root(s) that may involve access into the maxillary antrum
• Management of temporomandibular disorders and craniofacial pain that have not responded to initial therapy
• Treatment of cysts
• Management of suspicious/non-suspicious oral lesions
• The placement of dental implants (that are eligible under the NHS) requiring complicated additional procedures such as bone grafting, sinus lifts etc.
• Treatment of complex dentoalveolar injuries
• Management of spreading infections and incision of abscesses (or abscess) requiring an extra-oral approach to drain

Depending on the complexity of the procedure, consultant-led care may be required to manage any of the above and, in addition, is required for the procedures listed below. These procedures will be delivered within a team (which may include specialist trainees, specialists and SAS grades) who have appropriate ability and facilities to provide high quality care for patients:

• management of jaw and facial fractures
• management of congenital and acquired jaw anomalies
• advanced oral implantology and bone augmentation
• diagnosis and treatment of anomalies and diseases of the TMJ
• diagnosis and treatment of salivary gland diseases.

Third molars

Strict adherence to the NICE guidelines will be observed.

For clarity these include:

• Unrestorable caries
• Restorable caries in the adjacent tooth that necessitates extraction of third molar to restore the caries
• Non-treatable pulpal/periapical pathology
• Cellulitis
• Abscess
• Osteomyelitis
• Internal/external resorption of the tooth or adjacent tooth
• Fracture of tooth
• Disease of follicle (cyst/tumour)
• Documented pericoronitis on more than one occasion requiring medical or surgical treatment

Patients will normally only be offered a consultant appointment if:

• The request is for advice/specialist opinion only.
• The referral is accompanied by dated, current, relevant and accurately taken and developed peri-apical radiograph with the apex clearly viewable. When photocopies of digital radiographs are sent they need to be of a high quality and diagnostically useful.
• The tooth must be restorable after completion of the endodontic therapy. This must be determined by the referring practitioner prior to referral as most accepted cases will be sent back to the referring practitioner for final restoration following RCT.
• For posterior teeth it must be a strategically important tooth within the dentition as a whole. Specifically: it could be a functional tooth in a shortened dental arch, a tooth functioning as a partial denture abutment, a molar tooth when it is one of the patient’s only functioning pair of molars.
• The tooth has a curvature above 40 degrees in a strategically important tooth.

Patients will not normally be offered a consultation appointment if:

• It is a failed case with inadequate obturation e.g. poorly condensed GP, short or long root fillings or leaking coronal restoration in an otherwise straight forward case. These will be returned for treatment in primary care.
• The patient is not registered with a dentist.
• The patient states that they are ‘keen to save the tooth’ but the prognosis of such teeth is considered poor or unrealistic.
• They have poor plaque control or active caries.
• The current restoration is so large and/ or below the bone crest that isolation with dental dam cannot be achieved.
• That the patient requires or requests sedation or GA for endodontic treatment.
• The referral has been made on the patients inability / unwillingness to pay NHS charges.

Acceptance criteria

• Teeth with sclerosed or curved (>40 degrees) root canals that are not considered negotiable by a competent GDP from a radiograph of appropriate quality in a restorable tooth of strategic importance.
• For removal of posts/separated instruments where the post/separated instrument is retrievable and the tooth is restorable. This is a specific item of treatment and the patient may be sent back to practice for completion of the root canal therapy.
• Perforation repair in cases where this is feasible on strategically important teeth.
• Management of open apices, root fractures, resorption and trauma in young teeth.
• Peri-radicular surgery of failed anterior RCT in the presence of excellent quality obturation where orthograde re-treatment is not feasible and the rest of the mouth has controlled dental disease and there are high quality restorations present with no active periodontal disease.

To refer to this service please complete an endodontic referral form [doc] 624KB and send it to the endodontics team

All referrals for your periodontist must include all of the following:

• An accurately recorded six-point pocket chart.
• A plaque distribution chart and plaque score.
• Diagnostic radiographs of the affected sites clearly demonstrating periodontal bone levels (originals or print-outs of diagnostic quality).

Failure to include any part of the above in the referral will lead to rejection and delay in your patients care.

Acceptance criteria

Those patients likely to be accepted for consultation are patients with:

• Aggressive or severe chronic periodontitis, with pockets of >6 mm (BPE 4) with an excellent level of plaque control (plaque scores <20%) who have failed to respond to a full course of root surface debridement with local anaesthesia.
• Acute problems e.g. desquamative gingivitis, necrotising periodontal disease.
• Drug induced gingival conditions and localised gingival swelling (e.g. epulis).
• Localised significant root exposure in an otherwise periodontally stable patient.

Patients will not be accepted for specialist periodontal treatment if:

• The patients oral hygiene is poor/inadequate oral hygiene.
• There are obvious/gross gingival deposits.
• The patient has untreated primary disease, e.g. caries, retained roots.

It is a requirement that you will need to continue to see your patient for routine examinations and treatment (including emergency treatment) and continue to provide all other aspects of your patient's dental care including any recommendations made from the hospital specialists. For example, if the patient requires any extractions, restorations and or prostheses, it is expected that you will continue to provide these treatments in a timely manner.

To refer to this service please complete the restorative dentistry referral form [docx] 36KB and send it to the periodontics team.

All referrals for periodontitis must include all of the following:

• An accurately recorded BPE and where the score is four in any sextant must be accompanied by a full six point pocket chart.
• Diagnostic radiographs of the affected sites clearly demonstrating periodontal bone levels (originals or print-outs of diagnostic quality) except for complete dentures.

Failure to include any part of the above in the referral will lead to rejection and delay in your patients care.

Acceptance criteria

Those patients likely to be accepted for consultation are patients with:

• Diagnosis and treatment planning of complex prosthodontics cases - We are unable to see patients with multiple failing crown and bridgework.
• Patients with complete denture problems after a reasonable attempt to make well-constructed dentures in a primary care setting.
• Complex partial denture cases.
• Severe tooth wear cases – Many cases will be treatment planned and will be returned to General Practice for treatment.
• Complex occlusal problems – This does not include temporomandibular joint disorders or facial pain.
• Head and neck cancer patients: we are part of the multi-disciplinary team for Head and Neck cancer service covering North and East London. Referrals are accepted for comprehensive restorative treatment planning for patients prior to undergoing or have undergone surgical resection and/or radiotherapy to the jaws and oral structures due to cancer.
• Hypodontia: unfortunately these patients can not automatically be offered orthodontics or implant therapy and must be seen by a restorative consultant.
• Cleft palate patients: The Department of Restorative Dentistry at Barts Health Dental Hospital is the core provider of restorative/prosthodontic care for cleft lip and/or palate in the North Thames region. As a member of the North Thames regional Cleft Lip and Palate team we accept referrals from our colleagues at Great Ormond Street Hospital and Chelmsford Hospital. We are also able accept referrals for adult patients with cleft lip and/or palate requiring restorative/prosthodontic advice or treatment directly from General Dental Practitioners.
• Severe enamel or dentine maturation problems (amelogenesis or dentinogenesis imperfecta, fluorosis, severe tetracycline staining).

Patients will not be accepted for specialist periodontal treatment if:

• Poor/inadequate oral hygiene, calculus deposits and where there has been no attempt at disease control.
• Untreated primary disease, e.g. caries, retained roots.
• For re treatment of crown and bridgework of any sort.
• With implant work carried out at any other centre or practice.
• Temporomandibular joint disorders.
• For cosmetic dentistry of any sort.
• For reasons of cost.

To refer to this service please complete a restorative dentistry referral form [docx] 36KB and send it to the prosthodontics team.

Those patients likely to be accepted for consultation are patients with:

• Cancer of the mouth who have surgically lost significant amounts of mandibular, maxillary or facial bone structure. Other non-malignant pathological, acquired or congenital conditions may require similar surgery and management.
• Trauma – this is usually confined to the replacement of anterior teeth. It is expected that other methods for replacing missing teeth are considered as the first option, before dental implants are considered. It is expected that conventional treatment for traumatically lost teeth may eventually fail, despite being of a high standard and well cared for and such cases may be considered suitable for dental implant treatment.
• The patient must have excellent oral hygiene, controlled dental disease and missing teeth only at the site of the trauma.
• Hypodontia – Where there are congenitally missing teeth of strategic importance. Other treatment options such as resin retained bridgework may be deemed more appropriate.
• Sjorgrens syndrome patients where removable prosthesis are impractical. These patients must first have a positive diagnosis from a recognised UK oral medicine department
• Technically well-made complete over complete dentures that still have problems with control of the lower denture. N.B we only offer treatment in the lower arch
• Some patients who have been treated successfully in the hospital for aggressive periodontitis and have excellent oral hygiene practices with strategically important missing or hopeless teeth

Patients will not be accepted for specialist implant treatment at the hospital with:

• Poor/ inadequate oral hygiene, calculus deposits and where there has been no attempt at disease control
• Untreated primary disease, e.g. caries, retained roots
• Tobacco: There is sufficient evidence that smoking is detrimental to the healing and to the success of dental implants. Dental implant treatment will not proceed if the patient uses tobacco.
• With implant work carried out at any other centre or practice
• For cosmetic dentistry of any sort
• For patients for whom removable partial dentures are a reasonable option.
• For reasons of cost

To refer to this service please complete our restorative dentistry referral form [docx] 36KB and send it to the implant team.

All referrals should be from a dentist only to avoid inappropriate referrals and avoid unnecessary delay for your patient.

To refer to this service please complete a referral form [docx] 39KB and send it to:

• If a patient lives in Tower Hamlets email The Royal London Hospital team
• If a patient lives in Waltham Forest, Redbridge, Barking or Harlow email Whipps Cross Hospital team

Please note that we no longer accept postal or fax referrals. All proformas must be electronically completed and hand written forms will be returned. 

• Referrals will be accepted for advice, treatment planning and, for those patients meeting our acceptance criteria, they will be accepted for comprehensive treatment.
• Patients who are not dentally fit will not be accepted and should not be referred in the first instance unless they are fit for treatment.
• Those patients who are accepted for treatment will be expected to continue to be registered with a general dental practitioner.
• Patients can only be accepted where we have capacity to care for them.
• NHS England is committed to monitoring for the quality of referrals to secondary care. 

The following patients will be accepted for orthodontic assessment:

• Patients under the age of 18 years with high treatment need requiring complex orthodontic or multidisciplinary treatment. This encompasses patients having ‘great’ (IOTN 4) or ‘very great’ (IOTN 5) need for treatment, only where the required treatment is complex.
• Patients will not automatically be accepted for treatment based on IOTN score; and the complexity of treatment will first be assessed.
  • For example, where a patient has only crowding; or a patient has only an increased overjet; or a patient who has hypodontia with only one missing tooth per quadrant, or there is no need for the prosthetic replacement of any teeth, we may discharge them for and suggest onward referral to a specialist orthodontic practice.
• Patients with significant skeletal discrepancy eligible for combined orthodontic-surgical (orthognathic) (Royal London or Whipps Cross) care.
• Patients with developmental absence of teeth (hypodontia) (Royal London or Whipps Cross) meeting specific acceptance criteria.
• Patients with cleft lip and palate (Royal London only) according to our eligibility criteria.

The table below allows quick reference to IOTN DHC with the most common features.

	M	O	C	D	O
IOTN 5	Cleft lip & Palate Impacted/Ectopic teeth Hypodontia > 4 missing teeth	> 9mm Overjet > - 3.5mm reverse Overjet
IOTN 4	Supernumaries Hypodontia <4 missing teeth	> 6mm Overjet    -2mm to -3.5mm reverse Overjet	Crossbite with > 2mm displacement between RCP and ICP	> 4mm contact point displacement (adjacent teeth)	Deep Overbite + Trauma > 4mm Anterior Open Bite
IOTN 3		> 4mm Overjet < -2mm reverse Overjet	Crossbite with > 1mm <2mm displacement between RCP and ICP	< 4mm contact point displacement (adjacent teeth)	Deep Overbite (no trauma) < 4mm Anterior Open Bite
IOTN 2		> 2mm Overjet		< 2mm contact point displacement (adjacent teeth)
IOTN 1				Minimal irregularity

 

Acceptance criteria 

A fully comprehensive service, for children and adults, who are diagnosed with a cleft lip and/or palate. Our MDT team includes: consultant orthodontists from Barts Health and Great Ormond Street Hospital, a consultant maxillofacial surgeon from Great Ormond Street Hospital/University College Hospital and a restorative consultant from Barts Health. Our team also involves a clinical psychologist and speech and language therapist from Mid Essex Hospital Services NHS Trust.

Patients with complex allied craniofacial and medical conditions will be seen on the MDT clinics at Great Ormond Street Hospital (aged 16 or under) or at University College Hospital (aged 16 and over).

Care pathway 

All patients referred to Barts Health will have their letters vetted internally by a consultant and will be seen for comprehensive records and assessment of their needs before on the MDT clinic.

Referrals from consultant orthodontists from outside Barts Health for restorative care only will be booked directly on to the MDT clinic.

To refer to this service please complete our orthodontic referral form [docx] 39KB and send it to the cleft team.

General anaesthetia

Treatment will only be offered following an assessment initiated by the receipt of a completed referral form. Referrals are normally only accepted from the community dental services. If you are considering referring a patient from general practice, then please initially refer to the local CDS.

Adults accepted for consultation will be assessed and should their treatment needs be deemed manageable within the community dental services, they will be returned with appropriate advice.

Patients will be accepted for general anaesthesia if the patient:

• has moderate to severe learning disabilities
• has a congenital/ genetic condition that reduces the patient’s cooperation with routine behaviour management techniques
• has severe airway problems that are best managed under GA, and where IV sedation is contraindicated

is ASA I, II and III (ASA IV patients will still be assessed but may not be offered a GA following an anaesthetic assessment)

Referred patients who will not receive a consultation appointment for general anaesthesia

Referrals may not be accepted:

• if incomplete or insufficient information is provided i.e. “see and treat”
• if sent for financial / economic reasons
• if the patient has no special care needs other than dental anxiety
• if a GA is requested for social reasons e.g. if the patient cannot provide an escort for intravenous sedation
• if the patient has been directly referred by a GDP/GMP
• for common medical history problems that are manageable within CDS/GDS e.g. warfarinised patients

Sedation

Intravenous sedation will only be offered to patients over 16 years of age (or competent adolescents aged 14 years and over) and who are deemed to be appropriate for this treatment modality after a full assessment by a sedation dentist.

The range of treatment available under conscious sedation is limited to basic conservative care and extractions. Endodontic treatment of posterior teeth will not be undertaken. Advanced restorative treatment (including crowns and bridges) will not be provided under IV sedation*.

Patients will be accepted for sedation if the patient:

• is ASA I, II and III.
• has moderate to severe dental anxiety.
• has a gag reflex that limits dental treatment with behaviour management alone.
• has learning disabilities that reduces the patient’s cooperation with dental treatment.
• has an involuntary movement disorder that affects the safe provision of dental care.

*exceptions may apply at the discretion of the sedation dentist.

Referred patients who will not receive a consultation appointment for sedation.

Referrals may not be accepted for sedation if the patient:

• can be best managed by the community dental services.
• is ASA IV and above.
• requires intravenous sedation and has no suitable escorts to accompany them to the appointment and look after them post operatively.
• is pregnant.
• is referred for endodontic treatment in molar teeth.
• is referred for crown and bridge work.

Referral forms 

Please refer your patients to our services using one of our referral forms:

• Oral medicine referral form [doc] 195KB
• Oral and maxillofacial referral form [docx] 124KB
• Orthodontic referral form [docx] 39KB
• Paediatric dental referral form [doc] 98KB
• Restorative dental referral form [docx] 36KB