Appropriate consent and referral for general anaesthesia - a survey in the Paediatric Day Care Unit, Barnsley DGH NHS Trust, South Yorkshire

BACKGROUND: In November 1998 the General Dental Council introduced guidelines for dental practitioners when referring a patient for general anaesthesia (GA). The practitioner is required to explain the risks associated with GA and the alternatives, give a detailed medical history and a clear justification for providing GA in the letter of referral. METHOD: A survey was administered on 202 parents or guardians, which aimed to investigate whether they felt that their dental practitioners had advised them of any risks of GA prior to referral. A record was also made if any reasons were given for the provision of GA in the letter of referral. RESULTS: The majority of the parents or guardians (66%) felt that they were not informed of any of the risks of GA and 25% felt that they were. From the letters of referral, 37% contained a reason for GA and 63% did not give any reason or justification for GA. CONCLUSION: There is evidence that referring practitioners do not adequately explain the risks of the anaesthetic to parents or guardians of children undergoing GA. There is also a lack of clear justification in the letters of referral for providing GA. PRACTICE IMPLICATION: It is essential that the alternatives and the risks of GA are discussed and if GA is still required, a clear justification should be contained in the letter of referral as part of informed consent. More importantly the referring practitioner should keep a contemporaneous record of this, preferably with a signature from the parent or guardian on agreement of referral.     

Peer review amongst restorative specialists on the quality of their communication with referring dental practitioners

OBJECTIVE: A peer review study was carried out to assess the written communication between consultants and specialist registrars in restorative dentistry with the referring general dental practitioners. METHODS: Seven people took part in the study and each presented referral and reply letters for five patients whom they had seen for consultation. The referral letters were used for information only and were not used in the peer review process. Each participant inspected the referral and reply letters from the other six participants. The reply letters were anonymously peer reviewed by using a proforma containing agreed criteria in relation to appropriate factors to include in the reply letter. The reviewer also ranked the letter in relation to overall quality on a 1-10 point scale. RESULTS: It was found that the participants' letters generally conformed positively with the agreed criteria although there were some differences between individuals. There were particular problems identified in relation to tooth notation. Reply letters commonly used different forms of tooth notation to the referring practitioners. CONCLUSIONS: The ranking of the letters generally indicated that the participants' replies were judged to be favourable by their peers. There may be scope for continuing this study in relation to peer review by other groups of professionals, in particular practitioners in primary dental care.     

Accuracy of referrals to a specialist oral medicine unit by general medical and dental practitioners and the educational implications

In this study we investigated the accuracy of diagnoses of oral mucosal diseases made by family physicians (without a dental degree), other categories of physicians, and general dental practitioners prior to referring patients to a university oral medicine unit. Over a three-year period, we compared the diagnoses proposed in referral letters with the definitive histological diagnoses made by the specialist unit. Only 305 of 678 (45 percent) of the referral letters included a clinical diagnosis. Eighty-six patients (86/305, 28 percent) were referred by general dental practitioners (GDPs) who had graduated in dentistry; seventy-six (76/305, 25 percent) were sent by GDPs who had graduated in medicine with a postgraduate degree in dentistry; and 143 (143/305, 47 percent) were referred by other categories of physicians. More than 50 percent of the referring professionals were not able to make a clinical diagnosis of oral mucosal diseases. Only 40 percent of the provisional diagnoses (122/305) coincided with the diagnosis made at the specialist unit. The proportion of correct diagnoses was 40 percent for GDPs who had graduated in dentistry, 33 percent for other categories of physicians, and 27 percent for GDPs who had graduated in medicine with a postgraduate degree in dentistry. These findings suggest that Italian dental and medical practitioners have limited knowledge in the field of oral medicine. Consequently, there is a need for better education in the diagnosis and treatment of oral diseases and for improvement in total oral health training.     

A survey of specialist paediatric dental services in Sweden: results from 2003, and trends since 1983

The child population in Sweden has changed dramatically during the last 20 years. Changes have also occurred within the Public Dental Service (PDS), regarding the provision of dental care to children and adolescents. All these changes may affect the referral pattern and provision of specialist dental care for children and adolescents. OBJECTIVES: The primary aim of this study was to survey the services provided by specialists in paediatric dentistry in Sweden during 2003. A secondary aim was to compare the results with previous surveys. METHODS: A Web-based survey was sent to all 34 specialist paediatric dentistry clinics and was answered by all clinics. Data were compared with results from the surveys performed in 1983, 1989, and 1996. RESULTS: The number of paediatric dentists had been relatively constant over the last 20 years, whereas the number of children referred to paediatric dentists had increased by 28% since 1983. It was estimated that 1.3% of all children in Sweden are treated at a specialist paediatric dental clinic in 2003. Dental treatment need in combination with behaviour management problems (BMP) was the main reason for referral and occurred in 37% of all referrals. The proportion of medically compromised children/children with disabilities had increased from 6% in 1983 to 22% in 2003. The number of patients treated using sedation and general anaesthesia had increased since 1983, and particularly since 1996. CONCLUSIONS: Despite improvements in dental health among children and adolescents in Sweden during the last 20 years, an increasing number of children are referred for specialist paediatric dental treatment. There is an urgent need to increase the number of specialist paediatric dentists in Sweden in order to ensure the continuation of high quality of dental care for children and adolescents.     

A review of referral patterns to paediatric dental consultant clinics.

A retrospective survey of 317 child patients referred to consultant paediatric dental clinics at Glasgow Dental Hospital over a 12-month period is reported. It was found that although there was a wide range of reasons for referral the most frequent problem was the management of the patient. As a result of this finding, the dental hospital is currently establishing a clinic specifically for patients with a fear of dental treatment.     

An audit of the quality and content of periodontal referrals and the effect of implementing referral criteria.

AIMS: This audit aimed to assess the effect of implementing referral criteria on the quality and content of referral letters sent by general dental practitioners (GDPs) to the periodontal department of a teaching hospital.METHODS: Retrospective data were collected from a total of 450 referrals made in: (i) 1997, prior to any changes; (ii) 2000/2001, after referral guidelines were implemented; and (iii) 2004/2005, after referral criteria were redefined and circulated via Primary Care Trusts. A standardised data-collection form was used to record the information that was provided in the referral letters. This information was also compared to the findings at initial hospital consultations.RESULTS: There was a small improvement in the administrative details provided in the referral communications in 2000/2001 and 2004/2005. Medical history was often incomplete and was mentioned in 31-34% of referral letters. Use of the Basic Periodontal Examination (BPE) score increased from 17% (1997) to 57% (2004/2005). The information on clinical details otherwise increased in 2000/2001 with a tendency to decrease in 2004/2005. There was little agreement between the clinical details in the referral communications and the findings at consultation in the periodontal department.CONCLUSIONS: Following implementation of referral criteria, there was an increase in the clinical details provided in referral letters. However, the validity of the information provided by the GDPs was often questionable. The number of referrals that provided medical history details remained unchanged. Use of a pro forma was not associated with an improvement in the quality of referrals in this audit.     

An audit of study casts used to monitor tooth wear in general practice

OBJECTIVE: To assess the outcome of compliance of advice sent to patients and dentists about monitoring tooth wear in general practice. METHOD: Postal questionnaires were sent to 70 patients and their dentists requesting information on the outcome of letters of advice sent to general dental practitioners regarding monitoring tooth wear with study casts. They also requested information about the reasons for the patients' referral, the outcome of treatment and whether study models had been taken. RESULTS: Replies were received from 60 dentists (87%) and 53 patients (75%). Of these, 16 patients and 16 dentists had moved from their recorded address. Study casts were reported as having been taken by 23 dentists (38%) and reported by 18 patients (34%). The most common reason for referral was advice about monitoring the wear and the appearance of their teeth. CONCLUSIONS: The compliance of the patients and dentists in monitoring tooth wear by using study casts in general practice was not successful. It raises issues regarding the value of consultant advice letters to this common clinical problem.     

Appraisal of a standardised periodontal referral proforma.

AIM: The primary objective was to assess the standard of new-patient referral communications to the Periodontology Department of a teaching hospital and evaluate any differences in referral quality between referrals that used a standardised proforma and conventional letters. Secondary objectives were to evaluate the potential influence on referral performance of age, postgraduate qualifications and country of qualification of the referring practitioners. DESIGN: A retrospective analysis of a randomised sample of all referral letters and proformae received during a nine-month period. SETTING: Letters and referral proformae received by the Periodontal Department of the teaching hospital between 1 January and 30 September 1995 were surveyed. METHODS: An objective Categorisation System for Periodontal Referral Quality (CSPRQ) was devised and tested for inter- and intra-examiner reproducibility. The referral communications in the random sample were then categorised for quality. The year, country of qualification (UK or non-UK) and possession or otherwise of postgraduate qualifications for each of the referring dentists was ascertained from the Dentists' Register. A Standard Normal Deviants (SND), or Z-test was applied to the resulting data. OUTCOME MEASURES: Acceptability or unacceptability of referral letters and proformae, related to the age (assessed by year of qualification), country of qualification and possession or otherwise of postgraduate qualifications. RESULTS: A random sample of 378 referral communications (from a total of 2663) was analysed. Sixty-three of the random sample were referral proformae. The use of the referral proforma was associated with a highly significantly better (P < 0.01) referral performance, than the use of referral letters. There was a trend for referrals from the small numbers of practitioners who were Fellows in Dental Surgery or Masters of Science to be better than those from other practitioners. There was also a trend for use of the referral proforma to enhance the referral performance of practitioners who had been qualified for more than 20 years. Use of the referral proforma highly significantly (P < 0.01) improved the quality of referrals from non-UK qualified practitioners. CONCLUSIONS: In this study, the quality of periodontal referrals was associated for the better with the use of a referral proforma.     

Establishment and evaluation of a trauma clinic based in a primary care setting

OBJECTIVES: The aim of this study was to establish and evaluate a referral centre for the treatment of children with traumatized teeth in an area remote from a dental hospital. SETTING: The study was conducted in a Community Dental Service clinic in Cheshire, UK. METHODS: A dentist from the Cheshire Community Dental Service was trained in the treatment and management of traumatized teeth. Invite referrals to the trauma clinic in a health centre. The number and types of patients referred and treated at the trauma clinic were monitored. In addition, the parents of referred children and referring dentists were asked to comment on the acceptability of the service. RESULTS: During the first 12 months, 49 patients with 74 traumatized teeth were referred to the trauma clinic. The majority of the patients were referred by their dentist because problems arose following their initial management. Both parents and referring dentists were very satisfied with the service. CONCLUSIONS: The trauma clinic fulfilled a clinical need, and was well received by the parents of children referred to the clinic and by the local dentists.     

Reasons for referral of children to a general anaesthetic service in Northern Ireland

OBJECTIVE: To investigate, in a case-specific manner, dental practitioners' clinical and social reasons for referral of children for dental extractions under general anaesthesia and to relate these to separately obtained information. DESIGN: For each child referred to the community general anaesthetic dental extraction service, closed-ended questionnaires were completed by the referring practitioner, by the parent accompanying the child and by the assessing community dental officer. SETTING: The study was undertaken in the Craigavon and Banbridge area of Northern Ireland. RESULTS: A total of 177 completed the study, representing an inclusion rate of 93%. The children ranged in age from 3 to 17 years (mean 6.8 years) and previous experience of general anaesthesia for dental extractions was seen in 55 (31%). The most common reasons for referral were the requirement for multiple extractions (63%), the patients' anxiety or fear of dental treatment (60%) and the young age of the patient (60%), and the specification of these reasons was found to be significantly related to separately obtained indicators. A poor record of co-operation for treatment in the past was indicated in almost a third of cases and this indication was significantly related to low levels of co-operation for restorations. CONCLUSION: It appears practitioners have considered a range of factors in their decisions to refer children and there is information which supports these reasons in most instances.     

Unravelling referral paths relating to the dental care of children: a study in Liverpool.

OBJECTIVE: To describe primary care referral networks relating to children's dental care and the main influences on referral decisions taken by dentists working in a primary care setting. DESIGN: A postal questionnaire to all 130 general dental practitioners (GDPs) in contract with Primary Care Trusts (PCTs), and 24 Community Dental Service (CDS) dentists in Liverpool. OUTCOME MEASURES: Characteristics of patient groups and factors influencing the choice of referral pathway of children referred from primary dental care. RESULTS: There were good responses rates (110 [85%] GDPs and 22 [92%] CDS dentists). The two main reasons why GDPs referred children to hospitals were (a) for treatment under general anaesthetic (GA) or relative analgesia (RA) and (b) for restorative care of dentally anxious children. GDPs also referred anxious children requiring simple restorative care and/or RA to the CDS. Only eight GDPs (7%) cited a lack of experience as a reason for referral of dentally anxious children for simple restorative care, compared to 53 (48%) who cited a lack of RA facilities, and 25 (23%) who cited financial considerations. CONCLUSIONS: GDPs refer children to both hospital services and the CDS, and identify a lack of RA facilities and economic pressures as key reasons for referral.     

Influence of NICE guidelines on removal of third molars in a region of the UK

We investigated compliance in the West Midlands, UK with the guidelines issued by the National Institute of Clinical Excellence (NICE) on the indications for the removal of third molars. We audited the practice at three departments of maxillofacial surgery that take referrals from three districts of the West Midlands. Of a total of 300 referral letters 217 (72%) specified a NICE-compliant diagnosis. A total of 267 patients (89%) were advised to have third molars removed and all three units achieved 100% compliance with NICE guidelines. There was a concordance of diagnosis of 69% between referring general dental practitioners and attending oral surgeons (concordance was 79% if only those referral letters that carried a specific indication were considered). Disease-free wisdom teeth made up a mean of only 6% of all referrals.     

Reply letters following orthodontic consultations: an audit of Merseyside general dental practitioners' satisfaction.

OBJECTIVES: To assess the opinions of general dental practitioners (GDPs) working within the National Health Ser vice (NHS) in Merseyside regarding the length, format and appropriateness of consultant orthodontists' letters sent in reply to referral letters. MAIN OUTCOME MEASURES: These were GDPs' satisfaction with the length, format and content of the reply letters; GDPs' preferences for the information deemed necessary in such letters; GDPs' awareness of the status of their patients and the actions they were requested to undertake. METHOD: After piloting, questionnaires were mailed to 330 participating GDPs between August and October 2004. RESULTS: Two hundred and fifty-one (76%) questionnaires were returned. With one exception, the length of consultants' letters was thought to be adequate. Of the responding GDPs 82% stated a preference for summaries of the diagnosis and treatment plan to be presented in a list format rather than as free text. Aspects of the treatment plan were thought to be more important than the information about the examination. Following receipt of the reply letter only 71% of GDPs were aware of what was happening to their patients and 75% knew what actions they were to undertake. CONCLUSIONS: This audit provides evidence that GDPs consider that a significant portion of the information in consultants' reply letters is not needed. Relevant information may be poorly communicated.     

Delays in the referral and treatment of oral squamous cell carcinoma

OBJECTIVE: To investigate the delays in referral and treatment of patients with oral cancer. DESIGN: A retrospective study. SETTING: District General Hospital Maxillofacial Unit (MFU). SUBJECTS: 100 consecutive patients with invasive squamous cell carcinoma of the oral cavity referred to Rotherham District General Hospital Maxillofacial Unit (RDGH MFU) between 15th March 1993 and 16th January 1998. METHOD: Information collected at the time of referral and treatment was examined retrospectively. RESULTS: In the patients studied 72% were male, mean age 61.2 years (sd = 11.2, range 37 to 88) and 28% female, mean age 65.6 years (sd = 16.7, range 29 to 90). The majority of referrals were from medical practitioners (56%) and most of the remainder being referred by dental practitioners (36%). The patient delay was found to be the most significant with only 39% presenting within 4 weeks, 29% delayed more than 3 months. There was no statistical correlation between T-stage, alcohol or cigarette use and the patient delay in presentation. Having presented to a medical or dental practitioner 69% were referred within 1 week. There were no significant differences between the T-stages presenting to either medical or dental practitioners or in their delay in referral for each stage. There was no significant difference in age or sex distribution between the populations presenting to general medical or general dental practitioners. General medical practitioners were more likely to refer a patient urgently. Patients referred directly to the MFU were seen quickly but those referred via an indirect route were delayed. 95% of patients were treated within 6 weeks of first consultation. CONCLUSION: The majority of practitioners refer patients with oral cancer within 1 week. The most significant delay is that caused by the patient. Some practitioners referred patients to inappropriate specialties, leading to indirect referrals. This results in additional delay in the referral and treatment pathway. Education of the public and primary health care workers should continue. Opportunistic screening of the oral mucosa should be part of the dental check up, with possible targeting of patients at greatest risk, particularly heavy drinkers and smokers.     

Referrals to a secondary care dental clinic for anxious adult patients: implications for treatment.

OBJECTIVES: This study aimed to determine the methods suggested by general dental practitioners for management of patients with dental anxiety whom they refer to a dental hospital setting, the treatment modalities eventually used with such patients and the relationship between patients previous sedation experience and the current referral. METHODS: Consecutive referral letters (n = 125) for management of patients with dental anxiety over a 16 month period were analysed for content, including reason for referral and suggested treatment modalities. Patient records were also examined for previous sedation experience. RESULTS: From 115 referrals eligible for analysis, the dentists requested management of anxiety using pharmacological methods in 113 referrals with only two referrals mentioning psychologically-based treatments. In secondary care, 29% of the adult referrals opted for dental treatment using psychological techniques alone. CONCLUSIONS: In spite of the efficacy of psychological treatments for dental anxiety, primary and secondary care dentists appear not to be suggesting or promoting their use for patients with dental anxiety. Further research into the availablility of, and barriers to accessing the full range of services for those with dental anxiety, including patient perspectives, needs to be undertaken.     

Factors influencing referral for specialist endodontic treatment amongst a group of Dutch general practitioners

AIM: To analyse the need for endodontic referral amongst a group of Dutch general practitioners and to examine the current referral patterns and factors influencing the decision to refer. METHODOLOGY: A questionnaire was designed to investigate the perceived need for endodontic referral, the factors that influenced the decision process, the specialist to whom the case was referred and the frequency of referring. The questionnaires were distributed amongst 500 dentists attending a scientific meeting of the Netherlands Society for Endodontology (NVvE) and to 83 members of 10 study groups responding to a request in a newsletter. These groups were chosen to represent those dentists who possessed a similar degree of general dental knowledge and were acquainted with the requirements that endodontic treatment should meet. RESULTS: The response rate was 41%. Of the respondents, 93% felt the need to refer cases to specialists. The majority of dentists preferred to refer to an endodontist rather than an oral surgeon. The major factors considered to be important or very important (37 and 54%, respectively) for endodontic referral were the presence of an obstruction in the canal, followed by the presence of a perforation or resorption (43 and 34%, respectively) and persistent signs and/or symptoms (39 and 32%, respectively). NVvE members referred significantly less to oral surgeons than nonmembers. CONCLUSIONS: Amongst a group of Dutch general practitioners there is a substantial perceived need for referring endodontic cases to specialists.     

The effect of orthodontic referral guidelines: a randomised controlled trial

OBJECTIVE: To develop and evaluate the effectiveness of referral guidelines for the referral of orthodontic patients to consultant and specialist practitioner orthodontists. DESIGN: Single centre randomised controlled trial with random allocation of referral guidelines for orthodontic treatment to general dental practitioners. SETTING: Hospital orthodontic departments and specialist orthodontic practices in Manchester and Stockport. SUBJECTS: General dental practitioners and the patients they referred for orthodontic treatment. MAIN OUTCOME MEASURE: Appropriateness of referral, defined as whether the patient was accepted for orthodontic treatment. RESULTS: The referral guidelines did not reduce the number of inappropriate referrals. CONCLUSIONS: Referral guidelines for orthodontic referrals did not influence the behaviour of the general dental practitioners. More research into the optimum methods of dissemination and implementation of referral guidelines for use in the general dental service is needed.     

Quality of written reports provided by consultants in restorative dentistry to referring general dental practitioners in the west midlands.

OBJECTIVES: The primary objective of this study was to assess the views of general dental practitioners (GDPs) on the content, style, and readability of written reports provided by restorative consultants at a dental hospital in response to referral letters from the GDPs. The secondary objective was to determine the style of the written consultant report preferred by GDPs. SETTING: Referral letters received and replied to by four consultants in the restorative department at Birmingham Dental Hospital. METHOD: The quality of written reports sent by the four consultants to 100 referring GDPs in the West Midlands area was evaluated using a postal questionnaire, which assessed 100 GDPs' satisfaction with the content, style, and readability of the reports. To assess which format they favoured a second questionnaire was subsequently sent to the same GDPs with three versions of the original report in: (a) a standard format, (b) a summary format, and (c) a bullet point format. RESULTS: The results of the initial questionnaire revealed that 79 (96%) of practitioners were satisfied with the existing style of the reports. Following a second questionnaire in which GDPs were asked to choose which format they preferred, 61 (81%) expressed a preference for a bullet point or summary style report. CONCLUSION: The GDPs who responded to the questionnaires felt that a bullet point format or summary style report from the consultants concerned would summarise cases more clearly and concisely than the conventional standard format letters which they had previously received. Opportunities may exist for improving the quality of consultant reply letters through the use of structured templates and/or a summary or bullet point format.     

Patient satisfaction in a dental school.

PURPOSE: The objective of this study was to measure patients' satisfaction with the facility, services and treatment received at a dental school clinic. METHOD: The 31-item questionnaire consisted of demographic items and items in a 5-point Likert-type format addressing issues such as security, satisfaction with the facility, helpfulness of the staff, progress of treatment, fees, universal precautions taken, quality of care and treatment with dignity and compassion. The questionnaire also asked whether the patient would recommend the school to others seeking dental care. In 1997, patients completed the survey in the clinic waiting room prior to their dental appointment for that day. The survey was conducted over 3 months until 500 patients had participated, representing about 16% of the active patient population. %s of responses were computed and cross tabulations were used to compare responses based on demographics. RESULTS: The most frequently reported reason for wanting to be a patient at the dental school was low cost (67%) followed by up-to-date care (19%). 45% of patients indicated that a friend, neighbour or relative referred them, followed by 34% indicating referral by a dentist. More than 90% responded positively to the items concerning issues related to treatment except for satisfaction with progress of treatment and comparison of care received at the school to care elsewhere. For these 2 items, at least 80% responded positively. 99% indicated they would recommend the dental school to others seeking dental care. CONCLUSION: Results indicate that the vast majority of the patients surveyed are satisfied with the facility, services and treatment received. Comments that addressed areas of concern included the length of time to get an appointment and the length of time the appointment took, and it was recommended that the process of treatment be expedited.