A periodontist’s perspective on what happens after a referral

As clinicians, we often find ourselves needing specialist input - whether that is to obtain assistance answering a particular question, understanding the prognosis for a certain tooth/lesion, seek a second opinion, or addressing treatments that fall outside our expertise. 

Fortunately, guidelines do exist. These help us to diagnose, treat, and know when to refer, for example the British Society of Periodontology (BSP) guidelines for periodontal disease. 

Dentists might not be confident knowing when to refer, and this article discusses what actually happens once the patient is referred. 

The aim of this article is to shine a light on what happens at the ‘receiving end’. The article is based on my personal experience and explores the common phases of the journey from the perspective of a specialist in Periodontics. 

Referral 

The world health organisation defines referral as ‘a process in which a health worker at one level of the health system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the help of a better or differently resourced facility at the same or higher level to assist in patient management'. 

Referral to a specialist is indicated in cases where one or more of the following clinical criteria are identified: 

• Probing pocket depths of ≥5 mm accompanied by clinical attachment loss 

• Radiographic evidence of alveolar bone resorption 

• Tooth mobility not attributable to occlusal factors 

• Presence of furcation involvement (Class II or III) 

• Persistent signs of inflammation (e.g., bleeding on probing, suppuration) despite appropriate non-surgical periodontal therapy 

• Mucogingival defects or soft tissue anomalies requiring specialist assessment or surgical management 

• Complex medical history that may complicate periodontal treatment planning or outcomes (e.g. uncontrolled diabetes, immunosuppression, anticoagulant therapy) 

The type of referrals I receive vary. The referral letters range from a cryptic, generalised “please see this patient with periodontal issues” to those providing a detailed, comprehensive history. From a specialist perspective, the more information provided prior to meeting the patient, the more the initial appointment can be tailored to the patient’s specific needs. It is important to note that the referral letter is part of the clinical notes and therefore included in the bundle in dentolegal cases.

The referral letter should include the reason for referral, details of any preliminary periodontal therapy provided to date (including oral hygiene instruction and initial supra- and/or subgingival debridement), a summary of the patient’s medical history, including systemic or behavioural risk factors (e.g., diabetes, smoking) and, where available, recent diagnostic radiographs and any CBCT scans in cases involving implants or advanced bone loss. 

A well-written referral letter provides a comprehensive summary and is a record of clinical judgement, consent, and continuity of care. A copy of the referral letter, together with the specialist’s response, should be retained in the patient's notes. 

A best practice checklist 

• Details of referrer 
• Patient details 
• Clear clinical indication for referral 
• Patient informed and consented 
• Relevant clinical findings included (e.g., BPE, radiographs) 
• Medical history and previous treatment noted 
• Reasons for referral 
• Copy retained in clinical records 
• Referral made without unnecessary delay - A recurring theme in litigation is failure to offer a timely referral to a specialist. 

The BSP Guidelines for Periodontal Patient Referral document sets out referral guidelines for periodontal treatment and maintenance. It describes levels of complexity linked to the appropriate referral of patients in need of periodontal treatment in a secondary care setting and is available on the BSP website.¹ 

Initial assessment 

After acceptance, the first phase is the initial consultation. 

Once the patient walks through my door, before embarking on the clinical assessment, a thorough dental history will be obtained – including a detailed medical, social and dental history, as well as an attempt to understand why the patient feels they have been referred, and what their goals of treatment are. 

Notable periodontal risk factors will be assessed in detail – smoking (both cigarettes and vapes must be queried), diet, alcohol and stress levels, their occupation, as well whether there is any family history of susceptibility to periodontal disease or tooth loss. 

Current oral hygiene routines will be noted, including any oral hygiene aids that the patient may use. 

This allows me to build up a picture of the possible threats and contributory factors to both the level of disease as well as allowing me to foresee any challenges which may impact the provision of effective periodontal treatment. 

Following this, a thorough full-mouth clinical assessment will be performed, focussing not just on the regions/teeth in question, but taking a holistic approach to understand any other possible causes/exacerbating factors of the issue in question. 

Careful extra- and intra-oral assessments are performed – looking at all the soft and hard tissues, as well as the current standard of oral hygiene.

The occlusal relationship is noted, as are any carious teeth or defective restorations. 

Diagnostic tests 

The gingivae will then be assessed in great detail, with the use of either loupes or a microscope, in order to provide the clearest detail possible. 

Full-mouth periodontal charting is carried out (noting not just the pocket depths but also bleeding scores, mobility, recession and furcation involvement) and the appropriate imaging is then taken – either radiographs or CBCT scans. 

Further special tests (for example sensibility testing, blood tests) may sometimes be required. 

Establishing the correct diagnoses, and their severity, is reminiscent of detective work - all the relevant factors need to be carefully considered to allow you to arrive at the correct conclusion. 

Providing a tooth-by-tooth prognosis 

Once the results of the diagnostic tests have been carefully considered, a tooth-by-tooth prognosis can then be created.

The predictability of the required treatment can then be evaluated to allow both clinician and the patient to consider the broader picture.

This allows me to answer the patients’ key questions. What are the options available to treat the condition? How much treatment is involved? How long will it take? What are the chances of success? What happens if we decide not to treat? 

From a dentolegal perspective, some patients will ask why they weren’t referred sooner or seek an opinion on whether their own GDP has neglected their periodontal health. I make a point of advising them that I am not in a position to comment as I have no knowledge of previous discussions and conversations. It is important to stress this as at this juncture it may trigger a query, complaint or even allegations of supervised neglect. 

Treatment planning 

As with many dental conditions, there may be a number of possible approaches to dealing with the issue at hand. 

It is vital that each of these are fully considered and discussed with the patient, allowing them to carefully consider both the risks/benefits of treatment, as well as the consequences of non-treatment. 

This has the distinct advantage of ensuring that the patient will then be proceeding with full informed consent, which is not just a dentolegal requirement but also incredibly helpful in ensuring the patient’s cooperation with the treatment plan.

One of the most significant challenges a periodontist faces is educating and helping the patient change their habits in the long term. Without this, any clinical treatment will be unsuccessful and hence having the patient’s compliance and motivation is non-negotiable. 

To help with this, I find discussing the options together has the added benefit of giving the patient a feeling of “agency” over their treatment. The diagnosis has been co-discovered, and an agreed plan of action has been reached between the referring dentist, the specialist and the patient. This significantly improves the patient’s compliance and enthusiasm in their approach, as well as being a good indicator of the likelihood of success.

Communication – the triumvirate of referring dentist, specialist and patient 

Throughout the consultation it is made clear to the patient that the referring dentist is the “Captain of the Team”. They are the ones who have referred the patient in for an assessment, and it is only with their agreement that the treatment will be performed. 

Often, the referring dentist plays an active role in treatment planning and execution. This may involve the extraction of teeth with a hopeless prognosis, fabrication of a denture, or provide an opinion about restorative options.

Working closely as a team, with open lines of communication, is vital to ensuring the patient receives an outstanding level of care. A comprehensive written report is then sent to the referring dentist detailing the findings of the assessment, suggested treatment plans and any additional other treatment that is required. The patient also receives a full report, using “patient-friendly” terminology. 

This is the point at which patients may query previous aspects of care – such as why treatment hasn’t worked or why there has been a delay in their referral for a specialist opinion. Fully-documented and contemporaneous note-taking, as well as timely referrals are therefore vital in the primary care setting. 

Phone calls between specialists and referrers are not uncommon too – all of the above ensures that the findings from the consultation can be fed back accurately to the referring dentist, allowing both the dentist and the patient to confidently decide on the best way forward and the highest standard of care possible. It is important to make a note in the clinical records to reflect the discussions during the call. 

Following treatment 

The referring dentist is kept up to date as treatment progresses. Once the specialist treatment has been completed, a full review of the patient and their response to treatment is carried out. .

Given that periodontal disease is a chronic inflammatory disease, achieving long-term periodontal stability is the primary goal of treatment. Once I have successfully attained this, the patient is discharged back to the referrer as the active phase of treatment is complete. I do however recall the patients at regular intervals. I like to check that they remain periodontally stable and ensure that their condition has not deteriorated.

The outcome of the review is then communicated back to the referring dentist. 

To conclude – here are 5 key tips from being on the “receiving end” of referrals for many years. I hope these will allow you to both protect yourself whilst helping provide the best patient care: 

1. Have the conversation – if you haven’t raised the possibility of specialist referral as an option, you have no protection if the patient subsequently raises a complaint. 

2. When you do refer – explain to the patient why you are referring them. Having them on board the treatment journey helps both you, and them.

3. Referral letter – ensure it is detailed. Remember, it will be submitted as part of the dentolegal documentation. 

4. Maintain good communication channels with the specialist you have chosen – allows you to follow-up at appropriate intervals and to ensure you are providing the correct primary care service when required.

5. Don’t assume – Don’t fall into the trap where you have been seeing the patient for many years and therefore assume they are still periodontally stable. Familiarity may lead you to gloss over vital indicators – e.g. taking a detailed pocket chart because “they’ve been stable for ages anyway”. Look at your patient with a “new” pair of eyes at each visit. 

Dr Simon Stern 

Specialist in Periodontics 

BDS MJDF RCS Eng MClinDent MPerio RCS Ed 

The Perio Centre – 107 Harley Street, London W1G 6AL 

www.periocentre.co.uk 

References

1 https://www.bsperio.org.uk/assets/downloads/BSP_Guidelines_for_Patient_Referral_2020.pdf