Dundee Dental Hospital specialist services: restorative dentistry - who to refer

Patients most BOTH satisfy the general/dental factors AND belong to one of the categories detailed below to be considered for dental implant treatment.

Please note long-term monitoring and maintenance of implants and implant restorations placed at the Dental Hospital are not provided by the Dental Hospital and should be delivered within primary care which may incur a cost for the patient. Please ensure patients are aware of possible future costs prior to referral.

Patients with peri-implant disease who had their implant placement at the Dundee Dental Hospital and Research School or within the NHS services will likely be accepted for management.

For patients who have peri-implant disease and have had implant placement outside the hospital services, we only provide a service for removal of the affected implant. Replacement of implants removed for these reasons is not offered within the Dundee Dental Hospital and Research School.

For implant referrals, please provide up-to-date relevant radiographs. This might include bitewing radiographs, teeth with indirect restorations, retained roots, endodontically treated teeth or teeth of questionable prognosis.

Dental implants and edentulousness

The fact that a patient dislikes the thought of, or is unwilling to wear dentures, or would like to have their existing denture replaced by an implant-retained prosthesis does not in itself justify implant-based rehabilitation.

Implant-retained overdenture (not fixed bridgework) may be considered in specific clinical circumstances. Implant-retained restorations will only be considered once an optimised conventional denture has been constructed under the care of an experienced clinician and following a period of time to assess adaptation (normally a year). This denture will help to assess patient tolerance of the denture and serve as the first step (radiographic template/surgical guide) if implants are to be provided.

For many Endodontic referrals, a shared-care approach is adopted whereby specific stages of treatment are carried out within the hospital and the patient returned to the referring practitioner for completion of treatment.

For all cases, the tooth in question must be:

• Caries free, functional and the tooth considered predictably restorable.
• Within the aesthetic zone or a strategic molar.

It is essential that:

• An up-to-date periapical radiograph of diagnostic value accompanies the referral
• Primary dental disease has been stabilised.

Trauma to permanent teeth

Many traumatic injuries to the permanent dentition can be managed within primary care. Treatment outcomes are often more favourable if appropriate trauma management is carried out without delay. Therefore, referring clinicians are encouraged to provide immediate trauma management and follow-up, in keeping with guidelines (link below).

Please ensure tooth repositioning has been attempted and a splint placed prior to referral.

Guidelines available: 2020 IADT Guidelines for the Evaluation and Management of Traumatic Dental Injuries

An advisory service is available whereby referred cases will be assessed and treatment plans recommended to referring practitioners. These may include:

• Requests for a second opinion on tooth retention where the tooth is strategically important, including endodontic treatment as part of complex restorative treatment planning.
• Confusing/complex/atypical signs of odontogenic pain.

The Fixed and Removable Prosthodontic service primarily offers advice and treatment planning to referring practitioners.  Unless there is an educational need, patients will only be accepted for treatment when they belong to a priority patient group AND are not suitable for management within primary care. For all other cases, it is expected the patient will return to their practitioner for treatment. 

It is important that patients are aware their referral is for advice and treatment planning only and referrals must indicate that the patient has been informed of this. 

We do not routinely remake dentures. Requests for denture construction for patients out with the priority groups will be returned to the referring practitioner with a treatment plan. 

We cannot offer treatment outside of the categories below even if the referrer outlines that the case is outside of their current skill set.  

All patients referred for fixed and removable prosthodontic treatment planning should have stable oral health.  

For tooth wear referrals, please note: 

• We expect that the general dental practitioner should have identified and attempted to manage causative factors. 
• We are unable to treatment plan rehabilitation of tooth wear cases where there is an uncontrolled intrinsic or extrinsic causative factors OR uncontrolled primary disease. 

For patients with a suspected or confirmed allergy to dental materials, often appropriate materials are available locally for denture construction without referral to the Dundee Dental Hospital and Research School.  

For fixed and removable prosthodontic referrals, please provide up-to-date radiographs of relevant teeth. This might include bitewing radiographs, teeth with indirect restorations, retained roots, endodontically treated teeth or teeth of questionable prognosis. Study models are no longer routinely requested for these referrals unless they are of particular clinical insight to the referred case. 

Periodontal cases referred will be considered for specialist treatment if the referral criteria are fulfilled i.e. steps 1 and 2 of the British Society of Periodontology Clinical Practice Guidelines are completed in most cases of plaque induced disease. Even if treatment in secondary care is anticipated, initial therapy should normally be carried out in the primary care setting, including: 

• Appropriate advice given regarding the control of modifiable risk factors, particularly smoking and oral hygiene levels 

• Full mouth supragingival scaling and root surface debridement of pockets, usually under local anaesthetic 

• Periodontal charting recorded prior to and 2-3 months after completion of the above, which should be dated within 9 months of referral. 

It should be acknowledged that there can be a delay between referral to secondary care and assessment of the patient. It is advised that appropriate periodontal therapy is continued while waiting for the referral to be dealt with. 

Patients accepted for treatment of periodontal diseases should continue to receive routine dental check-ups and emergency/ acute dental management with their registered dental practitioner. Management of routine restorations should be attended to by the registered dentist unless contacted by Dundee Dental Hospital to confirm this treatment will be provided within DDH as well. 

Courses of periodontal therapy in primary care, including scaling and RSD, should be refrained from while the patient is under the care of the Dundee Dental Hospital for their periodontal condition. 

Patients will be discharged: 

• On completion of a course of treatment. Thereafter, the patient’s registered practitioner will be responsible for life-long supportive periodontal therapy. This is essential to maintain periodontal stability. 

• If insufficient oral hygiene levels for periodontal stability are achieved. Patients who, despite best efforts, have either a level of oral hygiene that is insufficient to maintain periodontal health, or who are unable to comply with the proposed treatment plan, will be discharged back to the referring clinician for supportive periodontal care within the primary care sector, accepting that a gradual deterioration is likely unless there is a significant improvement in oral self-care. 

• If the patient fails to attend for appointments or cancels several consecutive appointments. 

The resources of the department are limited and repeat courses of periodontal treatment for patients discharged within the previous 2-3 years are not offered unless there is a specific reason that it may be beneficial (receipt of a re-referral letter explaining the exceptional circumstances is required). 

Patients with suspected desquamative gingivitis or lichenoid reactions should be referred to the Oral Medicine department for assessment. 

For periodontal referrals, please include up-to-date radiographs which should include good quality imaging of teeth with deep pocketing. This might also include bitewing radiographs, teeth with indirect restorations, retained roots, endodontically treated teeth or teeth of questionable prognosis. Your referral must also include periodontal pocket charting (pre- and post- step 2 care), and recent plaque and bleeding scores demonstrating effective engagement.