IntroductionAmong the aims of undergraduate dental education both the General Dental Counciland the Quality Assurance Agency recognize that referral of patients to colleagues inthe dental profession is an integral part of clinical practise.

This is likely to become more commonplace with increasing emphasis on specialism,increased public awareness of what services and alternatives are available and increas-ingly specialized equipment and expertise are required. Referral is also a quality of careissue, and appropriate referral requires a range of professional, knowledge and attitu-dinal skills.

Under ‘The aim of undergraduate dental education’ the First Five Years (GDC 2002)states that:

The undergraduate dental curriculum must allow students to acquire the clinicalunderstanding in competence to practise without supervision, on graduation andat the same time to allow them to be aware of their limitations and need to refer forspecialist advice.

GDC (2002, paragraph 17)

The dental graduate must be able to communicate effectively with patients, theirfamilies and associates and with other health professionals involved in their care.

GDC (2002, paragraph 19)

Patient ReferralPeter Mossey1.13

◆ Referral of patients from primary care to secondary care is an indispensable partof clinical practice.

◆ Examination/diagnostic skills, underpinning knowledge, clinical judgement, selfawareness and recognition of own limitations are implied underpinning skills.

◆ A competent letter of referral requires an ability to communicate effectively andappropriately by the written word.

Key points

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It is essential that graduating dentists understand the limitations of their currentknowledge and clinical abilities. They should be aware of the range of treatmentsavailable, and of the current evidence to support their choices, but not be expectedto be able to provide them all. In such circumstances they must be able to refer foran opinion on treatment and management by a suitably experienced/qualifiedindividual.

QAA (2002, paragraph 1.6 )

Furthermore among the transferable skills outlined, the same document statesthat the graduating dentist should have the ability to communicate effectively at alllevels in both scientific and professional contexts using verbal, non-verbal andwritten means.

QAA (2002, paragraph 3.1)

Intended learning outcomesExposure to integrated oral care units, outreach, outpatient medical and dental depart-ments and ward-based referrals allows undergraduates to gain insight into a processand build on their knowledge until they become fully competent to make their ownreferrals.

The essential components of a competent referralLetter from a general dental practitioner in primary care to a colleague in secondarycare or in specialist practice should include the following:

1. Referrers details – the information should include name of referring dentist:

◆ Address (essential)

◆ Telephone number (desirable)

◆ Email address (optional)

2. Name of the person to whom you are referring the patient. This may be a specificperson, or a department in secondary care without specifying the individual.

3. Patient’s details must include name, address, telephone number and date of birth.

4. Presenting complaint: it is important to record the patient’s own perception of theproblem for which they are being referred. On occasion, views of a parent,guardian, older sibling or partner may be sought to obtain an accurate assessmentof how the patient perceives the problem for which they are being referred.

5. Medical history: comment on whether there is any relevant medical history andwhether or not the patient is on any drugs or medication. If so, this should be elaborated upon. Those aspects that are important for the general welfare of thepatient or that may have an impact on the dental treatment should be specificallymentioned. Women of reproductive age should be asked if they might be pregnant,

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and if not whether they are using contraceptive measures. Other relatively com-mon instances include allergies, diabetes, congenital heart problems or infec-tive endocarditis (requiring antibiotic cover for invasive dental treatment), and whether consultation with the patient’s medical practitioner would be advisable.

6. Dental history: in all disciplines, oral hygiene status, caries experience, teeth ofdoubtful prognosis and any areas of hypoplasia or decalcification will be relevant.In the dental history it may also be relevant to record previous exposure to anaes-thesia and radiography. The frequency of attendance and any concerns you mayhave about patient attitude, motivation or compliance based on your own experienceof the patient in the past.

7. Social history: should record patient’s social habits that may impact on dentalhealth such as smoking, alcohol consumption (particularly if it is felt that thismay be excessive), other siblings and ability to attend. For example, orthodontictreatment requires regular attendance over a prolonged time period and the levelof parental support and ability to attend should be recorded. It may also be usefulto advise if the patient can attend at short notice.

8. Family history may also be included, particularly if the condition for whom thepatient is being referred may have a familial or genetic contribution. Examples ofcommon conditions that may have some genetic contribution are malocclusion,periodontal disease, hypodontia, rarer conditions with a genetic contribution suchas cleft lip and/or palate or hereditary gingival fibromatosis and even more rare

THE ESSENTIAL COMPONENTS OF A COMPETENT REFERRAL

Table 1.13.1 Intended learning outcomes for referral

Be competent at

Making and acceptingreferrals to and fromcolleagues

Responding to a referralletter, fax, e-mail, telephonecall, and grade the degree ofurgency

Write a referral letter to acolleague with demographicdata, reason for referral,relevant backgroundinformation includingdental, medical and socialinformation and medication

Have knowledge of

Systemic conditions thatrequire appropriate referralfor dental treatment at aspecial centre

Reasons for referral tospecialist, hospital dentalpractitioner

Be familiar with

Complex cases that requirereferral (assisting withrecognition of personallimitations)

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single gene disorders such as dentinogenesis imperfecta, amelogenesis imperfecta,and cleidocranial dysostosis.

9. Reason for referral: provide appropriate detail on your examination, diagnosis,severity, differential diagnosis (if appropriate). Also describe the condition, perceivedproblem or aspect of treatment for which the patient is being referred. The oral softtissues should also be examined and anything unusual reported and well knownindices such as DMF, plaque and gingival indices might be noted.

10. Specify whether advice only is being sought or if the reason for referral is to havetreatment carried out in secondary care. It is helpful to indicate what aspects ofthe treatment you might be willing to do, e.g. extractions or restorative treatmentthat is within the scope of your own skills. There may be positive advantages todoing so such as avoiding a treatment waiting list.

11. Enclosures: any previous records may be extremely helpful in the diagnosis and treat-ment planning related to the presenting complaint. It is also regarded as unethicalclinical practice to repeat invasive procedures or records. The type of record willdepend on the nature of the referral but radiographs, study models, photographs or,on occasion, previous appliances, dentures or components of treatment. The referralletter should be signed and if the signature is illegible or difficult to interpret, a stampcan be used or the name may be printed in bold underneath.

Checklist 23 Letter of Referral

Marking scheme Yes No Not relevant

Date of referral

GDP details (name, address and phone number)

Name, address and DOB of patient

Reason for referral (advice and/or treatment requested)

Key details of clinical problem

Medical history and drugs

Dental history

Relevant social and family history

Indication of urgency of referral

Radiograph or other supporting documentation enclosed

Signature and printed name of referring practitioner

Letter reasonably clear and legible

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12. Abbreviations and jargon: while jargon and abbreviations should generally beavoided or explained, it is acceptable to use jargon or abbreviations that would reasonably be expected in the repertoire of the specialist to whom the referral isaddressed.

Hospital practitioners, specialist practitioners or those who limit their practise to particular aspects of dental care such as oral surgery, endodontics, orthodontics orimplantology may receive referrals from colleagues in primary care. Upon receipt ofsuch referrals they should respond to acknowledge receipt, and also to provide feedbackon how their patient is to be managed, or to provide the advice or assistance requested.This reply will vary according to the nature of the referral received. For further information on specialty specific referrals, references such as White et al. (2004) concerning referral for oral cancer and Djemal et al. (2004) for restorative dentistry areuseful. Details of these is beyond the scope of this chapter.

References and further readingDjemal S., Chia M. and Ubaya-Narayange T. (2004) Quality improvement of referrals to a

department of restorative dentistry following the use of a referral proforma by referringdental practitioners. British Dental Journal 197(2), 85–8.

GDC (2002) The First Five Years: a framework for undergraduate dental education, 2nd edn. London,The General Dental Council.

QAA (2002) Dentistry: academic standards. Subject benchmark statements. Gloucester, QualityAssurance Agency for Higher Education.

White D. A., Morris A. J., Burgess L., Hamburger J. and Hamburger R. (2004) Facilitators andbarriers to improving the quality of referrals for potential oral cancer. British Dental Journal197(9), 537–40.

REFERENCES AND FURTHER READING

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Patient

Parent, if child patient

Your concern

Referral Letters

Your details

Radiographs

Study models

Photographs

Name

Address

Telephone number

Your request

Advice only

Treatment

What you are prepared to do

Enclosures

Patient details

NameFormer name?

Address

Date of birth

Relevant medical history

Telephone number

Previous dental history

Regular attender

Oral hygiene

Caries state

Presenting complaint

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