Referral Criteria – Minor Oral Surgery Accepted Rejected Third Molar Removal Accepted for minor oral surgery for teeth meeting NICE guidelines Rejected – Treatment to be undertaken by GDPs Wisdom teeth meeting NICE criteria that are impacted requiring a flap procedure
• Impacted wisdom teeth free from disease
and bone removal and/or surgical division i.e. wisdom teeth which cannot be
• Upper 8s fully erupted with good vision and access
removed by forceps or through simple elevation
• Lower 8s with favourable roots that are fully erupted or have >3/4 crown visible
• Untreatable tooth decay• Abscesses• Cysts or tumours – onward referral to secondary care/ maxillofacial• Diseases of the tissues around the tooth• If the tissue is in the way of other surgery
Apicectomies Within primary care conventional root canal treatment should be the first treatment Rejected – Treatment to be undertaken by GDPs option for cases with periapical pathology. If unsuccessful, non-surgical re-treatment should be the preferred option for endodontic failure. Apicectomies cannot be performed without an adequate orthograde root filling.
• Unsuccessful conventional endodontic treatment on incisor, canine or premolar tooth
• Where the root canal therapy is inadequately obturated
where there is evidence of re-root treatment, and an adequate coronal seal. The roots
• Where patients have unstable and active periodontal disease i.e. where there is poor
should show successful and complete obturation i.e. close to the apex with good lateral
condensation and no evidence of coronal leakage.
• Unsuccessful conventional root canal treatment due to sclerosed or obstructed canal.
• Where the tooth has inadequate coronal tooth tissue to support a conventional crown
• Teeth with post crown and no evidence of orthograde root filling
• Patients must have caries removed prior to acceptance for apicectomy
• Where the tooth has not been previously restored
• Peri-radicular disease where iatrogenic (e.g. broken file) or developmental anomalies
• In the presence of subgingival caries or where coronal tissue has been lost to such an
(e.g. aberrant root anatomy) prevent non-surgical root canal treatment being
extent there is access to the root canal system which cannot be sealed i.e. where coronal
• Where a biopsy or peri-radicular tissue is required (persistent cyst or inflammation which
• Teeth with a post crown where the post is proportionally inadequately designed
• Teeth which have post crowns where the post does not fit the canal, or the post has
• Where perforation, root crack or fracture is suspected and requires visualised repair
• Where tooth sectioning or root amputation are required
• Teeth with a lack of surgical access
• Where it may not be expedient to undertake prolonged non-surgical root canal re-
• Patient factors – includes severe systemic disease and psychological considerations
treatment because of patient considerations
• Possible involvement of neurovascular bundle or maxillary antrum or other anatomical
features which compromise success of treatment
Medically Compromised Patients Requiring Non-mandatory Services (i.e. those not covered under a primary care dental contract) Accepted in Primary Care MOS Provider: Rejected – Treatment to be undertaken by GDPs
• Patients on anti-platelet drugs such as aspirin, clopidogrel are at risk of excessive
• Most patients with cardiovascular, respiratory disease, diabetes and epilepsy are well
bleeding and therefore can be treated by a specialist in primary care with liaison with
controlled on their medication and can be treated within the primary care setting.
the patient’s GP and will require sockets packed with a haemostat and sutured.
• Steroid therapy maintained at <7.5mg may not need steroid cover. Available evidence
• Patients taking Bisphosphonates and at low risk of developing BONJ only, these patients
suggests supplementation is unnecessary for Local Anaesthetic.
can be treated in GDS especially where the treatment will be traumatic i.e. Raising a flap
• Patients on Warfarin can be treated by a GDP if their INR is <3 (an extraction
appointment should be arranged 72 hours after the patient has attended the INR
Oral surgery within a hospital setting:
clinic to ensure INR is <3). Patients should have sockets packed with a haemostat (e.g.
Surgicel) and the sockets sutured following extractions/surgery. The patient’s GP must
be consulted for the prescribing of tranexamic acid mouthwash for the patient post
• Respiratory function decreased to the extent that the patient is on home oxygen therapy
extraction and used four times a day for 2 days. As with all extractions, and even more
importantly with patients taking anticoagulants, it is recommended that a written
instruction sheet with a telephone number for out of hours advice is given to the patient
• Any medical condition that requires additional investigations prior to extraction such
in case of bleeding. Patients taking Warfarin should be prescribed non-selective NSAIDS
and COX-2 inhibitors as analgesia following extractions.
• Patients with coagulation disorders such as Haemophilia, Von Willebrands Disease
• Ideally extraction appointments will be arranged the day after a visit to the INR clinic
• Patients on Warfarin whose therapeutic INR >3, or whose INR is unstable or requires
when a reading can be obtained and bought by the patient to the appointment.
• Patients taking Bisphosphonates and at a low risk of developing BONJ only can be
treated in GDS especially where the extraction is atraumatic. Patients at low risk of
• Patients who have had radiotherapy to the head and neck.
developing Bisphosphonate-related Osteonecrosis of the jaw i.e. patients about to start
bisphosphonate to prevent or manage osteoporosis can be treated in GDS. Atraumatic
• Steroid medication >10mg of prednisolone or equivalent dose of another steroid,
removal of teeth will provide a favourable outcome, healing needs to be reviewed after
as per BNF, in the last three months.
• Patients at higher risk of developing BONJ (Bisphosphonate-related Osteonecrosis of the
Jaw) including those with a previous diagnosis of BONJ, taking bisphosphonate as part
of the management of a malignant condition, other non-malignant systemic condition
affecting bone e.g. Paget’s disease, under the care of a specialist for a rare medical
condition e.g. osteogenesis imperfect, concurrent use of systemic corticosteroids or
other immunosuppressant, coagulopathy, chemotherapy or radiotherapy.
• Patients with a severe immune dysfunction• Angina at rest• Myocardiac Infarction < 6 months ago. Accepted Rejected Other Dento-alveolar Surgery The following, that may involve single or multiple extractions (including clearances) Rejected simple extractions on healthy patients which should be carried out in General may be accepted: Dental Practice
• Unsuccessful attempt at extraction by referring practitioner – this should be a rare
• Any tooth, root filled or not, with sufficient crown or roots to apply either forceps
• Severely abnormal root morphology likely to compromise ease of extraction
• Single rooted teeth and multi rooted teeth, whether root filled or not, that do not
• Root fragments situated in bone and difficult to remove by simple elevation or with
need division that could be elevated and removed with root forceps
root forceps. Roots in intimate proximity to anatomical features such as mental
• Root fragments situated wholly in soft tissue
• Upper 8s fully erupted with good vision and access
• Impacted or unerupted teeth that require removal as part of an orthodontic
• Exposure and bonding of teeth as part of an orthodontic treatment plan – patients
must bring gold chains with them for treatment
• Teeth with significant cystic/periapical areas that require enucleation• Teeth wth areas of unexplained root resorption
Soft Tissues (if included) Accepted by Primary Care MOS provider: Rejected – treated to be undertaken by GDP, as appropriate
• Mucocele if interfering with patient’s functionality
• Lower lip mucocele, no treatment if not interfering. The mucocele should
be monitored appropriately as spontaneous resolution may occur. Accepted in hospital setting: • White/red patch • Suspected cancer, under 2 week rule
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Huilbaby’s: een praktische en effectieve aanpak Samenvatting Carole Lasham In Nederland zoekt 22% van de ouders hulp in verband met het hui-len van hun baby. De meeste ouders zoeken hulp bij een consultatie-bureau, daarnaast 5% bij de huisarts, 2% bij de kinderarts en 6% in het alternatieve circuit. Huilen kan beschouwd worden als normaal biologisch gedrag. Het is een vorm van communicati