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Referral

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Referral criteria

In some cases it may be appropriate to refer a patient to a practitioner with advanced skills, a specialist practitioner or to secondary care for further periodontal care. These cases include patients with severe disease or where the treatment required is complex or complicated by other factors. The British Society of Periodontology has devised guidelines for referral based on three levels of case complexity, based on the 2018 Classification of Periodontal Diseases, with provision for modifying factors to be taken into account.134 Referral centres may also have local guidelines in place which will state the criteria for referrals from primary care.

In general, patients with uncomplicated periodontal diseases (Level 1 Complexity) should be treated in general dental practice. Patients with stage II, III or IV periodontitis (>30% bone loss) and residual true pocketing of 6mm and above (Level 2 Complexity) should receive initial non-surgical treatment (Steps 1 and 2 of therapy) in general dental practice but may be accepted for referral in specific situations. Patients with Grade C or Stage IV periodontitis (bone loss >⅔ root length) and true pocketing of 6 mm or more (Level 3 Complexity) should be referred once lifestyle or behavioural risk factors have been addressed and appropriate non-surgical treatment (Steps 1 and 2 of therapy) undertaken in general practice. For more information see the British Society of Periodontology BSP Guidelines for Periodontal Patient Referral.134

Consult any locally produced guidelines and the British Society of Periodontology BSP Guidelines for Periodontal Patient Referral134 to determine if the patient is a suitable candidate for referral.

In cases where referral is considered, carry out initial therapy (i.e. Steps 1 and 2 of therapy).

  • Provide oral hygiene advice and instruction to assist and encourage the patient to improve their oral hygiene skills as well as their understanding of the value of good self-care routines (see Oral hygiene).
  • Remove supragingival plaque, calculus and subgingival deposits using an appropriate method and ensure that local plaque retentive factors are corrected.

Where applicable, give information regarding personal risk factors and modifying them, for example, smoking cessation advice and diabetes control (see Smoking cessation and Control of diabetes).

In general, patients accepted for referral for periodontal care are expected to continue to attend their own dental practice for recall examinations and treatment, such as extractions or restorations, and are likely to be referred back for maintenance care. 

Formal Referral

Make referrals formally in writing or via the relevant online referral system and consider sending a copy to the patient. It can also often be helpful to make an initial contact, either by telephone or via a digital triage system, to discuss the case.

Keep a copy of the referral with the patient’s clinical notes.

Record in the patient’s notes the date of the referral and the reason for the referral. 

  • Follow up with the referral centre to ensure that the referral request has been received.

Include in the referral letter:

  • Referrer details: 
    • Name of referring General Dental Practitioner;
    • Address of referring practice; 
    • Email address of referring practice;
    • Date of referral; 
    • Telephone number. 
  • Patient details: 
    • Full forename, surname and title;
    • Full postal address including post code;
    • Gender;
    • Date of birth; 
    • Age; 
    • Home telephone and mobile telephone numbers;
    • Email address; 
    • CHI/NHS Number (if known); 
    • Details of the patient’s General Medical Practitioner.   
  • Medical History: 
    • Medical history, including details of any current medication.
  • Social History:
    • Smoking history; 
    • Information regarding special/social circumstances
      (i.e. Is there a family history of periodontal disease? Does the patient have hearing, visual, mental health difficulties or mobility impairment? Is an interpreter needed?).
  • Clinical Information: 
    • Diagnosis and classification;
    • Reason for referral;
    • Details of periodontal treatment previously carried out, including oral hygiene demonstration and PMPR;
    • Relevant radiographs* and periodontal charts;
    • Clinical images, if available.

*Ensure that radiographs are correctly orientated and labelled, for example by including the patient name, DOB/CHI, date radiograph taken and site in the filename or by ensuring that this information is clearly visible on the image.

Continuing care of referred patients

Provide supportive periodontal care (Step 4 of therapy) for referred patients who have been discharged after referral. 

  • Good communication with the referral practitioner and with the patient is vital to ensure the success of the treatment and long term maintenance.