Policy Directive

Oral Health Specialist Referral Protocols
Summary The Oral Health Specialist Referral Protocols PD is to establish clear and consistentpatient flow pathways for eligible NSW residents who require specialist oral healthservices. The policy also contains a referral form that supports continuum of carepractices between general and specialist services.

Document type Policy Directive
Document number PD2011_071
Publication date 17 November 2011
Author branch Centre for Oral Health Strategy
Branch contact 8821 4311
Review date 30 November 2017
Policy manual Patient Matters
File number
Previous reference N/A
Status Review
Functional group Clinical/Patient Services - Dental/Oral, Medical Treatment
Applies to Local Health Districts, Specialty Network Governed Statutory Health Corporations, Board
Governed Statutory Health Corporations, Chief Executive Governed Statutory HealthCorporations, Affiliated Health Organisations, Public Health System Support Division,Community Health Centres, Dental Schools and Clinics, Public Hospitals

Distributed to Public Health System, NSW Ambulance Service, Ministry of HealthAudience Clinical staff of oral health and medical services

Secretary, NSW HealthThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory
for NSW Health and is a condition of subsidy for public health organisations.

POLICY STATEMENTORAL HEALTH SPECIALIST REFERRAL PROTOCOLSPURPOSEThis policy statement and attached protocol aim to improve referral pathways frompublic and private medical and dental practitioners to public specialist oral healthservices by establishing clear and consistent patient flow pathways for eligible NSW
residents who require specialist oral health services.

MANDATORY REQUIREMENTS
Referral centres and referring practitioners are to ensure compliance with specific oral
health speciality referral criteria, as approved by Public Dental Services and theprocesses as detailed in the Oral Health Specialist Referral Protocol.
The oral health specialist referral form is to be completed by a referring practitioner
when referring a patient to a specialist service.

IMPLEMENTATION
Chief Executives must:

assign responsibility and personnel to implement the guidelines.



approve specific public dental services specialist referral criteria.

Medical and Dental Practitioners, Oral Health Clinical Directors and Oral HealthManagers must:

promote efficient patient flow pathways

monitor the implementation of the policy and specific public dental services criteria

Referral Centres must:Comply with the responsibilities detailed at section 3.3

Local Oral Health Staff must:comply with public dental services approved specialist referral processes andspecific public dental services criteria

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POLICY STATEMENTREVISION HISTORY
VersionApproved by

Amendment notes

November 2011
(PD2011_071)

Deputy Director-General
Population Health Rescinds PD2010_027
 Reissue updated to include generalanaesthesia services

 Reissue specialist referral form to include a
May 2010(PD2010_027)

September 1996
(PD2005_101)

Deputy Director-General
Population HealthDirector-Generaldate field Rescinds PD2005_101.
 Reissues updated specialist services referralclinical guidelines previously issued underIB2003_015
 Updates the specialist oral health referral form
Policy detailing the provision of orthodontic carefor dependent children of Health Card holders

ASSOCIATED DOCUMENTS
1. Oral Health Specialist Referral Protocols (attached)
2. Oral Health Specialist Referral Form 1

1

Salmat order number is NH606518 or alternative the form is located at Ministry of Health Website

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Oral Health Specialist Referral Protocols
PROTOCOLS
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Oral Health Specialist Referral
PROTOCOLS

CONTENTS1BACKGROUND ................................................................................................................... 1
1.1 About this document ..................................................................................................... 1
1.2 Key definition ................................................................................................................ 1
1.3 Patient Management ..................................................................................................... 1
1.4 Eligibility for Public Oral Health Services ....................................................................... 2
1.5 Related Policy Directives and Guidelines ...................................................................... 2

2

ORAL HEALTH SPECIALIST SERVICES ........................................................................... 3
2.1 Referral Centres............................................................................................................ 3
2.2 Specialist Service Type ................................................................................................. 3
2.3 List Management .......................................................................................................... 4

3

Referral processes.............................................................................................................. 4
3.1 Reason for Referral....................................................................................................... 4
3.2 Referring Practitioner Responsibilities ........................................................................... 4
3.3 Referral Centre Responsibilities .................................................................................... 5
3.4 Referral Centre Caveats ............................................................................................... 6
3.5 General Advice for Referred Patients ............................................................................ 6

4

General Anaesthesia for Dental Procedures..................................................................... 7
4.1 Key Referral Information ............................................................................................... 7
4.2 Index of Treatment Needs ............................................................................................. 7
4.3 General Anaesthetic Services ....................................................................................... 8

5

Conscious Sedation for Dental Procedures...................................................................... 8
5.1 Key information ............................................................................................................. 8
5.2 Index of Treatment Needs ............................................................................................. 9

6

Endodontics ........................................................................................................................ 9
6.1 Key referral information ................................................................................................. 9
6.2 Index of Treatment Needs ........................................................................................... 10

7

Oral and Maxillofacial Surgery ......................................................................................... 10
7.1 Index of Treatment Needs ........................................................................................... 10

8

Oral Radiology .................................................................................................................. 11

9

Oral Medicine / Oral Pathology ........................................................................................ 12
9.1 Key referral information: .............................................................................................. 12
9.2 Index of Treatment Needs: .......................................................................................... 1210 Orthodontics ..................................................................................................................... 13
10.1 Key referral information: .............................................................................................. 13
10.2 Index of Treatment Needs ........................................................................................... 14
11 Paediatric Dentistry .......................................................................................................... 16
11.1 Key referral information ............................................................................................... 16
11.2 Index of Treatment Needs: .......................................................................................... 16
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12 Periodontics ...................................................................................................................... 1712.1 Key Referral information ............................................................................................. 17
13 Prosthodontics ................................................................................................................. 17
13.1 Key referral information ............................................................................................... 18
13.2 Index of Treatment Needs: .......................................................................................... 18
14 Special Care Dentistry ...................................................................................................... 19
14.1 Key referral information ............................................................................................... 20
14.2 Index of Treatment Needs: .......................................................................................... 20
14.3 Special Care Dentistry Services .................................................................................. 20
15 Shortened Terms .............................................................................................................. 21
16 Definition of Terms ........................................................................................................... 21
17 References ........................................................................................................................ 22
Appendix A

Paediatric Patient - Referral Flowchart (Sample)....................................... 23.

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Oral Health Specialist Referral
PROTOCOLS

1BACKGROUND

1.1 About this document
This policy directive is aligned to the NSW Oral Health Strategic Directions 2005- 2010,
which sets the platform for oral health action in NSW into the next decade. The Oral
Health Specialist Referral Protocols reflects the operating principles:Create better experiences for people using health services



Make smart choices about the costs and benefits of health services.

The Oral Health Specialist Referral Protocols aims to improve referral pathways frompublic and private medical and dental practitioners to public specialist oral healthservices. By standardising procedures and protocols between referring practitioners
and specialist oral health services the policy will:

Increase the efficiency of specialist oral health services



Improve the continuum of patient careImprove the level of feedback to referring practitioners

The Oral Health Specialist Referral Policy and Protocols have been prepared by theCentre for Oral Health Strategy NSW and the State Oral Health Executive through aspecialist referral review working group.

1.2 Key definition
In this document the term: Must – indicates a mandatory action required that must be complied with.
 Should – indicates a recommended action that should be followed unless there aresound reasons for taking a different course of action.

NSW Public Dental Service
Throughout this document the term public dental service is used to describe the team ofadministration and clinical staff who provide public oral health services to eligible NSW
residents.

1.3 Patient Management
As stated in NSW Health Policy Directive PD2008_056 ‘Priority Oral Health Programand List Management Protocols’, dental treatment provided during a general course ofcare will depend on the patient’s oral health needs, as determined by the treating
clinician and as per public dental service’s policies. In a general course of care thetreatment that is provided should result in the patient being dentally fit.
Treatment flows depend on the severity and urgency of the condition; patients may beoffered an appointment or placed on a list. List options are: assessment, treatment,
referral and managed care. Should a patient require a specialist service following anassessment appointment, and they meet the clinical criteria for that service, a referral toa specialist Dental Officer can be made.
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It is important that each dental patient referred for specialist consideration has a generaldental clinician to act as his/her case manager. This clinician acts as the patient’s
advocate, first point of contact for specialist advice and follow-up and co-ordinator for
referrals to other dental or medical specialists. Without a general dental practitioner ascase manager, patients have the potential to undergo multiple cycles of specialist
assessment and treatment, preventing other patients from accessing specialist
assessments and treatments.
A guiding principle of the referral process, in both medical and dental practice, is thatthe patient remains under the clinical case management of the referring generalpractitioner. As such, the patient is to be managed at the referring oral health clinic forall emergency dental procedures, and for all presentations which are not covered by thereferral and for ongoing management and follow-ups after the specialist course of careis completed.

1.4 Eligibility for Public Oral Health Services
The NSW Health ‘Eligibility of Persons for Public Dental Care’ policy directive defines
eligibility for public dental care for NSW residents. Adult patients will require a valid
health care card or pension card to qualify for specialist oral health care.
Only adults (18yrs and over) who are self holders of valid Centrelink concession card
are eligible for in-patient specialist dental services including orthodontic surgery and for
non-admitted procedural dental specialist services such as endodontics, orthodontics,
oral surgery, prosthodontics and periodontics.
All children and young persons (0-<18yrs) are eligible:• to be referred for consultation• for the provision of non-admitted treatment in all specialties, except orthodontics• for admitted paediatric dental specialty services for conditions outlined in 11.2.1– 11.2.4
However, only children and young persons (0-<18yrs) who are self holders or whoseparents/guardians are holders of a valid Centrelink concession card, are eligible for
admitted paediatric dental specialty services for conditions outlined in 11.2.5 and 11.2.6
and for any orthodontic specialty service.
Exemption to these eligibility criteria can only be made for patients for teaching
purposes and those patients with special clinical needs as authorised by Clinical
Directors of Local Health District Oral Health Services or their formally authorised
delegate/s. For these cases a service charge may be applicable.

1.5 Related Policy Directives and Guidelines
This Policy Directive should be read in conjunction with:Prevention of Osteonecrosis of the Jaw (ONJ) in Patients on Bisphosphonate
Therapies 2Consent to Medical Treatment – Patient information 32 http://www.health.nsw.gov.au/policies/gl/2010/GL2010_010.html
3 http://www.health.nsw.gov.au/policies/PD/2005/PD2005_406.html

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Oral Health Specialist Referral
PROTOCOLSCorrect Patient, Correct Procedure and Correct Site 4Data collections – Disclosure of unit record data held for research or managementof health services 5Eligibility of Persons for Public Dental Care’ 6Medical Records in Hospitals and Community Care Centres7

Oral Health Record Protocols 8Priority Oral Heath Program and Wait List Management 9

Records – Principles for Creation, Management, Storage and Disposal of HealthCare Records 10Student Training and Rights of Patients11

Waiting Times and Elective Patient Management Policy 12

2

ORAL HEALTH SPECIALIST SERVICES

2.1 Referral Centres
Public oral health services in NSW provide specialist dental care at the three major oral
health teaching facilities (Referral Centres) which are mainly associated with the
University of Sydney, Faculty of Dentistry.
These Referral Centres are:

Sydney Dental Hospital (SDH), 2 Chalmers Street, Surry Hills 2010, telephone:
02 9293 3200.

Westmead Centre for Oral Health (WCOH), Darcy Road, Westmead 2145 or
PO BOX 533, Wentworthville 2145, telephone: 02 9845 7178.



The Children’s Hospital Westmead, Dental Department, Westmead, corner of
Hawkesbury Road and Hainsworth Street, NSW 2145, 02 98452582.

Other NSW Local Health District Oral Health Services may also provide a limited rangeof specialist services. For further information contact the local Oral Health Service Call
Centre (refer to http://www.health.nsw.gov.au/cohs/contacts.asp) closest to the patient’s
place of residence.

2.2 Specialist Service TypeThe following specialist services are offered:General Anaesthesia

4 http://www.health.nsw.gov.au/policies/pd/2007/PD2007_079.html
5 http://www.health.nsw.gov.au/policies/pd/2006/PD2006_077.html
6 http://www.health.nsw.gov.au/policies/PD/2009/PD2009_074.html
7 http://www.health.nsw.gov.au/policies/PD/2005/PD2005_004.html
8 http://www.health.nsw.gov.au/policies/pd/2008/PD2008_024.html
9 http://www.health.nsw.gov.au/policies/pd/2008/PD2008_056.html
10 http://www.health.nsw.gov.au/policies/PD/2005/PD2005_127.html
11 http://www.health.nsw.gov.au/policies/pd/2005/PD2005_548.html
12 http://www.health.nsw.gov.au/policies/pd/2009/PD2009_018.html

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Oral Health Specialist Referral
PROTOCOLSConscious sedation for dental procedures



Endodontics

Oral and maxillofacial surgery

Oral radiologyOral medicine, oral pathology

Orthodontics



Paediatric Dentistry

Periodontics



Prosthodontics

Special Care Dentistry

2.3 List Management
Referral Centres who place referred patients on a wait list for either assessment or
treatment are required to inform both the patient and the referring practitioner. NSW
Health has developed a policy directive for Waiting Times and Elective PatientManagement, which identifies benchmark waiting times.
Note: that specialist waiting lists are not to be included in LHD general wait lists (refer to
POHP and List Management Protocol Policy Directive).

3

Referral processes

3.1 Reason for Referral
Referrals may be made for the following reasons:An opinion only, regarding a specific condition or a particular aspect of thepatient’s care;Management of a specific complaint or condition, subject to acceptance of thereferral; orOngoing management of a patient whose oral health condition/overall medical
status dictates that his/her oral health treatment needs to be undertaken by aspecialist clinician/institution, subject to acceptance of the referral.

3.2 Referring Practitioner ResponsibilitiesComplete the oral health specialist referral form and write the date of the referralon the form.

Ensure that all fields are completed for every patient. This includes:
Patient’s full name, address details and phone number,Medicare card number, including the eleventh digit and expiry date;Any entitlement card numbers, stipulating type and expiry dates;Copies of relevant radiographs including OPGs (to avoid unnecessary repeat
radiation exposure);

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Oral Health Specialist Referral
PROTOCOLSAccess issues and special requirements where relevant; andAny medical test results.
A brief medical history and indication of disability.

Ensure that the contact details of the referring practitioner are clearly recorded on
the form.

Ensure that the contact details (including telephone numbers) of the patient’s
general and specialist medical practitioner/s are clearly recorded on the form.

When complete, post or transmit the referral form to the appropriate specialist
service/referral centre.

Send only one referral per clinical issue. That is, do not send a referral to multiplereferral centres to increase the probability of an early outcome. Similarly, do notrefer for multiple clinical issues on the same referral form, e.g TMJ, exodontia andendodontics, as this risks the referral being held up in one specialist department,
while the second or third issue do not get prioritised.



Inform the patient that waiting times for assessment and treatment usually apply,
and that, until a specialist course of care commences, all dental treatment is to be
managed at the local general dental practice level.

3.3 Referral Centre Responsibilities


Acknowledge receipt of the referral in a timely manner.



Log patient details into the NSW Health Information System for Oral Health(ISOH), attach the referral form to the patient’s paper record and place a scanned
copy into the patient’s electronic record in ISOH.



Review the referral (to a Specialist or Department Head) in accordance with theSpecialist Referral Policy and Protocols and specific LHD referral criteria.



Prioritise the patient according to identified need.

Contact the patient to offer a consultation appointment. Inform the patient and thereferring practitioner if wait lists are applicable for either consultation or treatment
appointments.

When an offer of assessment has been returned unacknowledged, the Referral
Centre is to discontinue the referral and return the referral to the referring clinician
for local management.

Advise the referring practitioner of the outcome of the consultation/s and the
proposed course of care, or the reasons for not proceeding with specialist service.

Advise the referring practitioner on how to best manage the patient whilst waiting
for a general anaesthesia if deemed required.



Consult with the referring practitioner when proposed specialist care will impact onongoing general oral health care and when necessary return the patient for
general treatment to be completed before specialist services can commence
Maintain patient records by

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Oral Health Specialist Referral
PROTOCOLSretaining a copy of the Specialist Referral Form and the original or duplicatedradiographs as appropriate; and

attaching relevant documentation on the feedback process.

Comply with NSW Health Consent to Medical Treatment – Patient Information
policy directive by informing the patient and/or carer/guardian about the risks andbenefits of procedures such as intravenous sedation or general anaesthesia.

3.4 Referral Centre CaveatsAll referrals will be logged for consultation if they meet Specialist Referral criteria.



Depending on the outcome of the specialist consultation, including further tests oranalyses, a referral may not necessarily lead to treatment.



Patients who do not meet the criteria for specialist referral will not automaticallyqualify for general treatment at the Referral Centre and will be returned to thereferring clinic.

Post-graduate trainees, students, registrars, or general dentists/therapists/hygienists may provide some or all of the treatment as appropriate under
supervision of a specialist.

3.5 General Advice for Referred Patients
The Referral Centre should advise the referred patient and/or their carer/guardian that:

They need to bring their valid Medicare card as well as any other entitlement cards(e.g. health care card or pension card) to their consultation appointment and theirfirst treatment appointment.

Should a patient’s eligibility status change during the course of treatment, they
may be required to meet the costs of completing the treatment.



If they are unable to consent to treatment a legal guardian must accompany themto the assessment appointment.

Treatment will continue only if patients actively maintain good oral health status,
including compliance with recommended changes of behaviour (e.g. effective oral
hygiene, cessation of nail-biting, wearing of functional appliances) and attendancefor diagnostic tests.



Patients have a right to an interpreter or Aboriginal Liaison officer/health worker ifthey require assistance (Consent to Medical Treatment – Patient information PD).
The interpreter or Aboriginal Liaison officer/health worker may attend the patient’s
appointments and the Referral Centre can organise this. (Note: that thisinformation is to be logged into ISOH.)

The initial specialist appointment is a consultation only to assess dental needs.



If accepted for a specialist course of care, patients will invariably be placed on atreatment wait list, in accordance with the urgency of their assessed dental needs.

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Oral Health Specialist Referral
PROTOCOLSTreatment under oral sedation, intravenous sedation or general anaesthesia will
be determined by the appropriate specialist service and not by the referring
clinician.

4

General Anaesthesia for Dental Procedures

The need for general anaesthesia (GA) represents the clinician’s ultimate solution totreating a patient’s dental problem. The decision to recommend general anaesthesia is
not to be taken lightly as a risk of serious complications always exists. When deciding
to place a patient under general anaesthesia, the treating dental clinician must consider
the whole care of the patient.
To be exempt from a service charge, referred patients must hold a valid Centrelink
entitlement card (e.g. valid health care card or pension card) (Point 1.4).

4.1 Key Referral Information
Prior to GA assessment appointments must be made to ensure a suitable treatment
plan has been proposed and consented to, the patient’s behaviour is such that asatisfactory outcome can be achieved and a home-care program is established which
includes such aspects as tooth brushing instruction, referral to a dietician, instruction on
the use of home fluorides and follow-up visits, as appropriate.

4.2 Index of Treatment Needs
Certain clinical situations strongly indicate the need for general anaesthesia, these are:

Severe odontogenic cellulitis or abscess/sFacial trauma

Surgical management of pathology

Multiple carious teeth requiring extraction and/or restoration

Patients indicated for GA are to be assessed in accordance with the American Societyof Anaesthesiologists (ASA 2008) categories of anaesthetic risk. These are:

ASA Class 1

Health patient

ASA Class 2

Mild to moderate systemic disease without significant limitations

ASA Class 3

Severe systemic disturbance without limitations

ASA Class 4Life-threatening systemic disorder

ASA Class 5

Moribund patient not expected to survive >24hrs



ASA Class E

Emergency patient

Most patients who are ASA 1 or 2 will be suitable for day-stay anaesthesia.
However, patients with more severe systemic disease (ASA 3 or 4) may need overnighthospital care to ensure that they are maintaining their airway, tolerating oral food andfluids, that any pain is satisfactorily managed and that there is no ongoing bleeding.
This overnight hospitalisation would be in an acute or general hospital.
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Oral Health Specialist Referral
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4.3 General Anaesthetic Services
General anaesthetic services for dental procedures are provided by a multidisciplinary
anaesthetic and anaesthetic assistant workforce with specialist dental expertise in the
management of the patient’s presenting oral health condition (QG 2009).
Dental treatment made available under GA can be provided by a dental specialist, ageneral dentist who has been appropriately credentialed by local public dental services
and/or a post-graduate specialist registrar under appropriate supervision.
The patient will have a pre-anaesthetic assessment with an anaesthetist prior to the GA
to ensure that the patient is in an optimal state of health for the planned procedure (QG
2009).
The GA may be postponed if the anaesthetist determines risk factors such as:Medications have not been attested by the patient, such as warfarin and/or
bisphosphonate;Respiratory tract infection; orPatient has not fasted according to hospital instructions.

5

Conscious Sedation for Dental Procedures

Sedation for dental procedures (with or without local anaesthesia) includes theadministration by any route or technique, of all drugs that result in depression of thecentral nervous system. Conscious sedation offers an efficient and effective way ofproviding the patient with profound anxiety relief and pain management during dental
procedures.
For further information, refer to the Australian & New Zealand College of Anaesthetists,
Faculty of Pain Medicine Australian and New Zealand College Of Anaesthetists,
Gastroenterological Society of Australia, Royal Australasian College of Surgeons,
Australasian College for Emergency Medicine, College of Intensive Care Medicine ofAustralia and New Zealand, Royal Australasian College of Dental Surgeons, Royal
Australian and New Zealand College of Radiologists Professional Document PS9(2010): “Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional
Medical, Dental or Surgical Procedures”.
To be exempt from a service charge, referred patients must hold a valid Centrelink
entitlement card (e.g. valid health care card or pension card) (Point 1.4).

5.1 Key information
The choice of general anaesthesia or conscious sedation will be decided at the
specialist assessment/consultation using specific criteria based on health assessment,
treatment complexity, behavioural problems and an anxiety assessment.
Detailed instructions will be given to the patient before any appointment for sedation or
general anaesthesia. The patient must have a responsible adult to drive them home
after the procedure.

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5.2 Index of Treatment Needs
Referral for Conscious Sedation procedures includes patients in the following
categories:

Paediatric

Dento-alveolar surgery

Special Care Dentistry

Dental and/or needle phobias

Patients who are unsuitable for Conscious Sedation include:IV drug users

Methadone patients

Patients with psychiatric disordersPatients with significant health problems, e.g. ASA III or higher

6

Endodontics

All referred patients must hold a valid Centrelink entitlement card (e.g. valid health care
card or pension card) (Point 1.4).
Prior to referral for endodontics it is essential that:

The tooth is functional, free of active dental caries and well temporised by thereferring practitioner. This may require placement of an orthodontic band.

The referring clinician understands and accepts responsibility for all emergency
and other dental care of the patient whilst waiting for specialist treatment.

All other restorative treatment is completed prior to referral.

Where the patient is advised that a tooth is assessed as endodontically untreatable,
they will be returned to the referring clinician for management.

6.1 Key referral information
Teeth that can be added to an existing functional partial denture without detriment to apatient’s oral condition will not be considered for endodontic treatment.
Additional factors that must be considered are the:
Status of the root canal per se and the reason for treatment (calcified, blocked,
perforated, incompletely filled);Condition of apical third of the root canal (i.e. open, closed, resorbed or eroded);Strategic value of the tooth to the patient’s future restorative needs, for example,
as an abutment tooth for a denture.



Patient’s medical and psychological conditions, age or infirmity which may impact
on treatment provision or outcome;Number of teeth already lost in the arch and presence of a partial denture

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Oral Health Specialist Referral
PROTOCOLSOverall extent of treatment required in the mouth

6.2 Index of Treatment Needs
Patients will be placed on waiting list for definitive endodontic treatment according to thefollowing Priority Codes:
6.2.1. Priority 1 (High Priority)Traumatized and avulsed teeth. These include luxated, avulsed andfractured teeth.



Teeth with resorptive lesions or abnormalities. These include dens
invaginatus & dens evaginatus, external or internal root resorption.

6.2.2. Priority 2 (Medium Priority)Multi-rooted, restorable teeth important for function with difficult accessto pulp chamber, or complications following attempted endodontic
treatment, in a well maintained mouth.

Re-treatment cases, with history of pain, involving removal of root fillingmaterials, procedural errors and cases involving surgery.

6.2.3. Priority 3 (Low Priority-Unlikely to be offered specialist care)7Single rooted teeth in a well maintained mouth that require
straightforward endodontic treatment not necessarily requiring specialist
attention.

Unopposed multi-rooted restorable functional teeth:∼

in a poorly maintained mouth with no prospects of sustainableimprovement in periodontal condition, or∼in a heavily restored mouth requiring multiple endodontic
therapies.

Oral and Maxillofacial Surgery

Oral and maxillofacial surgery offers treatment to patients requiring surgicalmanagement of trauma, developmental disorders or diseases involving the dento-facial,dento-alveolar or dento-maxillary complexes and associated structures.
To be exempt from a service charge, including anaesthetic, theatre and ancillary fees,
referred patients must hold a valid Centrelink entitlement card (e.g. valid health care
card or pension card) (Point 1.4).

7.1 Index of Treatment Needs
The scope of Oral and Maxillofacial Surgery Services is broad and includes:
7.1.1. Emergency treatment

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Oral Health Specialist Referral
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Trauma - management of fractures of the facial skeleton including the
primary and secondary management of hard and soft tissues and otherinjuries involving the mouth, jaws and associated structures.



Other - management of acute infections of the jaws and associatedareas including complications following dental treatment eg bleeding,infection.

7.1.2. Dento-alveolar surgery

Management of complex oral surgical procedures such as, endodontic
surgery, removal of impacted teeth, management of benign tumours
and cysts of the oral cavity, and oral surgical management of patientswith significant medical problems.

7.1.3. Orthodontic / Orthognathic Surgery

The investigation, diagnosis and surgical correction of deformities of theface, jaws and related structures, including cleft lip and palate, utilising
the principles of, and in association with, orthodontic management.

7.1.4. Prosthetic and pre-prosthetic surgery

8Surgical preparation of hard and soft tissues for prosthodontic
treatments.



The placement of implants into the jaws to provide retention for
prostheses to replace missing teeth and/or missing tissues.

The placement of extra-oral implants can provide retention for a rangeof prostheses, such as maxillo-facial prostheses. These procedures areusually managed in conjunction with a maxillo-facial prosthodontist.

Oral Radiology

This service provides intra-oral imaging for specific diagnostic needs, extra-oral planarand panoramic imaging, including cone beam volumetric imaging for:

Pathology screening and case work-up;Oral surgery case work-up;

Prosthodontic case work-up including implant case work-up;

Orthodontic/Orthognathic case work-up;

Endodontic screening;Paediatric dental screening; and

Periodontal screening.

With the advent of digital radiography, it is possible to take radiographs at referral
centres or remotely, e.g. at acute care hospitals or private radiology practices, and havean oral radiologist or other dental specialist interpret the images. This electronictransmission or teleradiography may assist in rapid diagnosis, or even avoid patient
travel.
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9Oral Medicine/Oral Pathology

Oral Medicine/Oral Pathology provide tertiary diagnostic and clinical services to thestate of NSW by referral only. Services include:







Oral medicine/oral pathology
Management of the severely medically-compromised patient requiring oral/dental
care and treatment.
Management of conditions including the diagnosis of malignancy and treatment inconjunction with the Head and Neck clinical team.
The investigation and management of diseases of the salivary glands.
The diagnosis and management of patients with oral manifestations of autoimmune diseases.
Facial pain

9.1 Key referral information:
To be exempt from a service charge, referred patients must hold a valid Centrelink
entitlement card (e.g. valid health care card or pension card) (Point 1.4).

9.2 Index of Treatment Needs:
Indications for referral are patients with:
Any form of suspicious oral lesion or disease;
Suspected cases of mouth/oral cancer and pre-cancerous conditions;
Complex oro-facial pain whose cause has defied explanation and treatment; andExtensive or complex medical conditions that are best treated in a hospitalenvironment, for example:
haemophiliacs,
post organ- and bone marrow-transplant recipients; andpatients who have had radiotherapy treatment to the head and neckregion.
There are 3 priority categories as identified below:






9.2.1. Priority 1 (to be seen within two (2) working days/48 hours)

Suspected oral malignancy

Severe, incapacitating (unable to eat or drink) oro-pharyngeal ulceration



Severe, intractable, incapacitating oro-dental pain unrelieved bynarcotic opiate agents

Active dental/periodontal infection in a seriously immuno-compromised
patient (chemotherapy or head and neck radiotherapy recipient,patients on significant immuno-suppressant therapy, especially anti-Tcell agents or cytotoxic drugs)

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9.2.2. Priority 2 (to be seen at the next available appointment, or within four (4)weeks)


Significant intractable oro-pharyngeal ulceration or oro-dental pain
unrelieved by narcotic analgesics

Patients with suspected oral malignancy awaiting definitive radical
surgery, radiotherapy or chemotherapyPrior to head and neck radiotherapy treatment

Pre-transplant (organ or haemopoietic stem cell) or pre-heart valve
replacement dental assessment.

9.2.3. Priority 3All other cases.

10 Orthodontics
The criteria for referral of patients for public orthodontic services are as follows:Orthodontic treatment will not be offered to patients who are not dentally fit, that is,
who have active caries, chronic marginal gingivitis or whose oral hygiene is notsound.
Referrals must include details of the malocclusion, as listed in the table oftreatment need (Table A), and a recent panoramic radiograph (OPG);
If the patient is assessed as eligible for, and in need of, public orthodontic care thesupervising Dental Officer should refer the patient to a designated Dental Officer
for prioritisation of care. Note: A designated Dental Officer is a public dental
officer who has sufficient orthodontic knowledge and expertise which includes:the ability to recognise the need for interceptive care;the ability to undertake minor orthodontics; and,



the ability to prioritise severe cases for referral to specialists.

10.1 Key referral information:
To be exempt from a service charge, referred patients must hold a valid Centrelink
entitlement card (e.g. valid health care card or pension card) (Point 1.4).








Orthodontic treatment will only be offered to those patients who are dentally
fit and who maintain an excellent standard of oral hygiene.
If a patient does not maintain excellent oral hygiene during treatment anddoes not respond to an improvement program, orthodontic treatment may bediscontinued.
Patients must bring a valid health care card or pension card to every visit.
Any patient with a severe classification is likely to be accepted for treatment.
Any patient with a moderate classification should be referred and assessed
for suitability.
Any patient with a mild classification will not be accepted for treatment.

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






Any patient falling into the ‘Other’ category may be referred for assessment.
All patients accepted for orthodontic treatment who are assessed as requiring
a combined orthodontic/surgical (orthognathic) treatment must be a self
holder or whose parents/guardians are holders of valid Centrelink concession
card at the time of Request For Admission for surgery. If the patient underorthognathic treatment is no longer the holder or dependant of a Health Card
Holder, then the patient’s orthognathic surgery may be treated as private orcompensable and the patient or parents/legal guardian will be responsible forpayment of all fees raised by the hospital and providers. Such fees may
include medication, bed costs, special nursing, surgical plates and screws,
anaesthesia fees etc.
The referring clinician should be able to recognise the need for earlyinterceptive treatments and facilitate these treatments which may prevent
more serious orthodontic problems in the future.
The patient should be at an appropriate stage of development for the
proposed orthodontic care.

10.2 Index of Treatment Needs
An internationally recognised system of classifying need, the Index of Orthodontic
Treatment Need (IOTN) has been adapted. It is presented below in table format forease of use and understanding by referring clinicians (Table A).
Seven occlusal traits are listed:

overjet

overbite

crowdingcrossbitereverse overjethypodontia

open bite

For each trait, there is a description of severe, moderate and mild. This will determine
whether the patient is accepted for treatment.
Table A: Orthodontic Treatment Needs
MALOCCLUSION
OverjetOverbite
Crowding
Crossbite
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SEVERE(eligible)> 7 mm

MODERATE(Refer for opinion)
5 – 7 mmMILD
(Not eligible)< 5 mm100% coverage of lower
incisor or complete topalatemore than 70%
coverage of lower
incisorup to 50% coverageof lower incisor> 9 mm per arch

5 – 9 mm per arch

< 5 mm per arch

anterior/posterior

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MALOCCLUSIONSEVERE(eligible)
crossbite with:

enamel loss

gingival trauma

and/oranterior/posteriorcrossbite with functional
shift

MODERATE(Refer for opinion)
crossbite of morethan 2 teeth
and/orMILD(Not eligible)
crossbite of 1-2 teeth
with no functional
shiftunilateral posteriorcrossbite

Reverse overjet

Presence of reverse
overjetedge-to-edge

Hypodontia

multiple missing teeth
with major orthodontic
implications

one tooth missing
with moderateorthodontic
implications

Hypodontia with noneed for orthodontic
treatment>4 mm

2 – 4 mm

< 2 mmOpen bite
Anterior or Posterior

Other

Impacted/ectopic teeth
other than third molars
severe skeletal
malocclusions/orthognathic cases
facial deformities/
congenitalabnormalities/cleft lip
and palate (CLD)

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11 Paediatric Dentistry
All children and young persons (0-<18yrs) are eligible to be referred for paediatricspecialist consultation, for the provision of non-admitted treatment and for admitted
services for conditions outlined in 11.2.1 – 11.2.4.
However, only children and young persons who are self holders or whose parents/
guardians are holders of a valid Centrelink concession card, are eligible for admitted
paediatric dental specialty services for conditions outlined in 11.2.5 and 11.2.6.
Exemption to these eligibility criteria can only be made for patients for teaching
purposes and those patients with special clinical needs as authorised by Clinical
Directors of Local Health District Oral Health Services or their formally authorised
delegate/s. For these cases a service charge may be applicable.

11.1 Key referral information
For children in Group 6 (Point 11.2.6 below), attempts should be made to treat themusing behaviour management techniques prior to referral. Referrals in this category
should document these attempts to demonstrate which techniques have beensuccessful and which have not worked.

11.2 Index of Treatment Needs:
The sub-sections below list conditions for which specialist paediatric dental services areprovided at Sydney Children's Hospitals Specialty Network (Randwick and Westmead),
Sydney Dental Hospital and Westmead Centre for Oral Health.
11.2.1.

Group 1: Emergency Carephone the department directly if necessary for all children and young
persons aged 0 – 17 years, including:Facial swelling or acute oro-facial infection

Uncontrolled dento-alveolar haemorrhage

Dento-alveolar trauma

11.2.2.

Group 2: Children/Young persons
whose medical condition or general health is threatened if dental care is
not provided, such as but not limited to:Congenital/acquired cardiac condition;

Oncology; and/or

Haematological diseases

11.2.3.


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Group 3: Children/Young persons
with severe/chronic disease and /or functional disability, or with special
health needs, such as:Intellectually or physically disabled
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11.2.4.

Requiring frequent medications
Group 4: Children/Young persons
with congenital or acquired malformations of the jaws, face or teeth,orofacial pathology, such as:Craniofacial malformations e.g. clefts of lip and/or palateDental anomalies, such as amelogenesis imperfecta, multiple
supernumerary teethDento-alveolar pathology such as cysts, ulcers

11.2.5.

Group 5:Children 0 – 5 years
at high caries risk, such as:

Early childhood caries (either white spot demineralisation or cavitatedlesions)

Requiring management under general anaesthesia or sedation

11.2.6.
Group 6: Children/Young persons
with behaviour management difficulties, such as:Children over 6 years of age with extreme dental anxiety requiring
management under general anaesthesia or sedation

12 Periodontics
The criteria for referral of patients for periodontic services are:

Assessment and management of periodontitis.

Patients must demonstrate a commitment to good oral hygiene, smoking
cessation and attendance at appointments.
Specialist consultation for reasons other than periodontitis as follows:
pre-surgical consultations,management of soft tissue lesions,assessment for crown-lengthening,management of oral manifestations of systemic disease,assistance with treatment planning etc.

12.1 Key Referral information


Patients with gingivitis only are generally not accepted for treatment in thespecialist department.

13 Prosthodontics
Referring practitioners are advised, when practical, to discuss the referral with a
specialist before referring their patient. It is essential that the patient has received a

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course of comprehensive care to ensure no pathology remains and the only remaining
treatment need is that for specialist consideration.
If there is found to be outstanding treatment needs other than those specificallyaddressed in the referral, these will be directed back to the referring clinic, resulting indelayed specialist treatment.

13.1 Key referral information







Patients who have lost their dentures, who are dissatisfied with a recently
fabricated denture or who have only one or two teeth missing do not need a
specialist prosthodontic referral. These are general denture services which arewithin the capability and responsibility of local health districts.
The referring practitioner remains responsible for the oral health and well being of
the patient, including pain relief during the waiting period. Provision of temporary
restorations is essential to ensure the stability of the remaining dentition while
awaiting a specialist appointment.
Any additional laboratory costs arising from specialist treatment are to be borne by
the patient. The patient must be made aware of this prior to the referral.
Ocular prostheses (prosthetic eyes) are provided by ocular prosthetists and not by
maxillofacial prosthodontic specialists.

13.2 Index of Treatment Needs:
Patients will be considered for:
Fixed dental prosthodontics
crown and bridge work for dentate and partially dentate patients, forexample:13.2.1.

 excessive incisal/occlusal wear; coronal restoration of endodontically treated teeth; over-closed vertical dimension; and cases requiring cast-metal based dentures which are not responsive to
local efforts.
Removable prosthodontics
in cases identified below:

13.2.2.

 A history of serious problems, chronic clinical complaints or dissatisfaction
where all generalist efforts have been exhausted, for example:∼

chronic non-retention;∼

chronic denture soreness; and∼inability to wear an otherwise satisfactory prosthesis

 A medical condition such as

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undergoing head and neck radiotherapy,∼

salivary hypofunction/xerostomia,
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severely atrophic maxillary or mandibular ridges,∼

flabby ridges,∼

severe gag reflex, and∼significant anatomical defects such as mandibular or maxillary tori
or cleft palate.

Fixed and/or removable prosthodontics
for complex cases involving

13.2.3.

 Precision attachments;
 Osseo-integrated implants; and Hybrid therapies
Complex cases may include:

13.2.4.

 gross occlusal wear not consistent with the patient’s age; advanced tooth wear resulting from uncontrolled erosion, attrition,
abrasion, occlusal collapse, or where restorative treatment will require multi-disciplinary management.
13.2.5.

Jaw function and oro-facial pain
where there is no untreated pathology

13.2.6.

Chronic TMJ dysfunction
it is essential that the referring practitioner has commenced occlusal
splint therapy and advised the patient on other pain relieving actions e.g
moist heat packs when the case is acute

13.2.7.

Specialist dental prosthetic treatment
is provided to patients with oro-facial deformities, such as: Intraoral - Dentures, speech appliances or other appliances for alveolar
resections, hard or soft palate fenestrations, cleft palate, mandibular
resection and deviation, velo-pharyngeal incompetence, glossectomy odeformities resulting from surgical resection, reconstruction and orradiotherapy.
 Maxillo-facial - These mostly involve developmental or acquired facialdisfigurement in which plastic surgery is contraindicated and a cosmetic
prosthesis is required. Typically these cases involve an auricular, nasal ororbital prosthesis.

14 Special Care Dentistry
The Referral Centres offer specialist services to a diverse client group with a range of
disabilities and complex additional needs. This includes individuals and groups who
have a physical, sensory, intellectual, mental, medical, emotional or social impairment
or disability or, more often, a combination of a number of these factors.
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14.1 Key referral information

If the patient is unable to consent for his/her own dental treatment, the treatment
plan will need to be discussed and consent for treatment signed by the legal
guardian prior to commencement of care. Ability to consent must be noted in thereferral and, if the patient does not self-consent, the name and address andcontact details of the legal guardian must also be included
A parent/carer/guardian is required to be present at all appointments for thosepatients who are unable to consent, or who have significant physical orcommunicative disability.

14.2 Index of Treatment Needs:
To achieve positive outcomes for the referred patient, the Referral Centres offer special
services to address specific medical and/or social needs. These Referral Centres need
the commitment of the patient/carer/parent/guardian to aspire to good oral hygiene 13
and attendance of appointments.

14.3 Special Care Dentistry Services
Specialist services are as follows:Persons with mental illness/disorder/condition or disability (behavioural, and/or
intellectual) who are not suitable for routine dental care or are living in Aged residential care (retirement villages) or nursing homes hostels, group homes or boarding houses
 the community with their families or with help form professional carer






Persons who are homeless
Persons with serious medical conditions
Persons with physical disabilities (unable to walk unattended by carers, or using
wheelchairs, walking frames, callipers, scooter or other mobility aid
Persons with sensory disabilities of a severity which preclude routine attendanceat Public Oral Health Clinics

13

Good oral hygiene is achieved by the effective removal of dental plaque through twice daily tooth brushing including interdental
areas and using fluoride toothpaste and augmented with antimicrobial agents (eg. mouthwashes). Individuals must be instructed in
the most appropriate technique of oral health care that includes professional feedback and reinforcement to prevent relapse anddisease progression (Löe, 2000)

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15 Shortened Terms
ASA

American Society of Anaesthetists

CJD

Creutzfeldt-Jakob Disease

CLD

Cleft lip and palate

GA

General Anaesthesia

HIV

Human Immunodeficiency Virus

HIV/AIDS

HIV/Acquired Immune Deficiency Syndrome

IOTN

Index of Orthodontic Treatment Needs

OPG

Panoramic Radiograph

POHP

Priority Oral Health Program

SDH

Sydney Dental Hospital

TMJ

Temporomandibular Joint

WCOH

Westmead Centre for Oral Health

16 Definition of Terms
Term
In-patient
Non-admitted

Dental Caries

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Definition
Someone who stays overnight or for sometime in a hospital for treatment or observation(Collins 2004 pg 198)
The type of clinical service provided to a nonadmitted patient in a non-admitted patient
service event, such clinical services that areincluded are; allied health and/or clinical nurse
specialist; dental; imaging; medical; obstetrics
and gynaecology; paediatrics; pathology;
pharmacy; psychiatric; surgical andemergency department (Australian Institute of
Health and Welfare 2005).
A chronic multifactorial life style based oraldisease of microbial origin affecting the hardtissues of the tooth, commonly known as
dental decay or cavities. Dissolution of thecalcification tissues of the tooth by acidproduced from ingested refined carbohydrates
and micro-organisms in dental plaque. The
process by which cavities are formed in teeth
by gradual destruction of enamel and dentine.
(Barnett, L.V 2000)

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17 References
American Society of Anaesthesiologists (2008) ‘Standards, Guidelines and Statements’.
Park Ridge, IL: ASA
Australian Institute of Health and Welfare (2005) Non-admitted patient service type,version 1, DE, NHDD, NHIMG, Retrieved online 27 April 2010
http://meteor.aihw.gov.au/content/index.phtml/itemId/270090
Barnett, K.V (2000) ‘The Manual of Dental Assisting’, 4th Edition. Dental Assistants’
Association of Australia Incorporated. Elsevier Mosby, Sydney.
Collin, P (2004) Dictionary of Medical Terms, Fourth Edition, Bloomsbury Publishing,LondonLöe, H. (2000) Oral Hygiene in the prevention of caries and periodontal disease,
International Dental Journal Vol 50, pp. 120-130. Retrieved online 23 February
2009 http://www.fdiworldental.org/assets/pdf/commission/97_6_2.pdf
Queensland Government (2009) ‘Children’s Anaesthetic Services’. Clinical Services
Capability Framework, Version 3.0.
http://health.qld.gov.au/cscf/docs/4_child_anaes.pdf
Royal Australian and New Zealand College of Radiologists (2010): “Guidelines on
Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or
Surgical Procedures”, Professional Document PS9PD2011_071

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Appendix A Paediatric Patient - Referral Flowchart (Sample)

Treating clinician
considersspecialist referral
criteria

Referral form
accepted

Complete referral
form and forward toReferral Centre

Clinician decides
to refer patient

No

Letter sent to Patient &referring clinician

Yes

Patient’s oral
health needs
assessed

Generalanaesthesia
requiredNo

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Decide on clinicalcategory

Placed on Specialist outpatient Waiting List

Placed on statewide Paediatric /Specialist GA
Waiting List

Letter to referring
clinician indicating
on how to manage
patient whilst
waiting for GA

Allocated for surgery
by clinical priority
status, waiting timeand postcode

RFA Completed

Pt placed on Hospital
Surgical List

Yes

Allocate SAP
Clinical Priority
Category

ReferralCentre
CentreReferral
Administration
Administration

NeedAssessment
Assessment
Need

ReferralCentre
CentreReferralReferring Clinician
Administration Referring Clinician
Administration

Paediatric referral patient pathway

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