Feb12
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/guidanceon-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
complications
in
medically
compromised
patients
/
potential
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