NHS referral guidelines

With uncertainty about future contract procurement looming and waiting lists growing by the day, NHS orthodontics is down but not out, so relevant and timely referrals from our GDP colleagues remain vitally important.

As with so much in life, there isn’t a “one referral fits all” solution, but hopefully the following guidelines will help to streamline your orthodontic referral process.

So, let’s start at the beginning.  How do clinicians assess whether a patient may qualify for NHS treatment or not?

First is their age.  NHS orthodontics is only available to those under 18 years of age, although there may be some capacity for complex adult cases, requiring an interdisciplinary approach, to receive treatment within the hospital service.

Secondly, is the severity of their malocclusion. This is determined using the Index of Orthodontic Treatment Need (IOTN) which consists of an Aesthetic Component (AC) and a Dental Health Component (DHC) which looks at a variety of different aspects of the occlusion including:

• Missing teeth
• Supernumerary teeth
• Overjet both increased and reversed
• Overbite both deep bite and open bites
• Lateral open bites
• Crossbites both anterior and posterior
• Ectopic teeth
• Infraoccluded deciduous teeth
• Impacted teeth
• Contact point displacement

The IOTN allows us to breakdown an individual’s malocclusion and quantify each of the above factors.  We can then allocate the appropriate DHC grading, from 1-5.

Those patients that fall into grades 4 and 5 are deemed to have a clear need for orthodontic treatment and will be offered treatment under the NHS.  Those malocclusions that are graded 1 or 2 are considered too mild to receive treatment under the NHS and may need to consider accepting the current alignment of their teeth or considering treatment on a private basis.

It becomes a little more complicated for those borderline cases falling within the grade 3 category.  This is where the AC can be implemented.  The AC consists of 10 colour photographs which are compared to our patients’ teeth.  If they score grade 6 or above on the AC, they are then deemed eligible for NHS treatment.

The IOTN is not the easiest index to use, so I would request that my GDP colleagues always inform patients that they may not qualify for NHS treatment despite being referred under the NHS, unless there is a clear indication that they will. There are courses run by the British Orthodontic Society (BOS) for those that would like to gain a better understanding of the IOTN and learn how to effectively implement it in practice.  The BOS also provide a Quick Assessment and Referral Reference Guide for those unfamiliar with the IOTN.

Now we have established those patients that qualify for NHS orthodontics, we need to ensure they are referred to the correct provider, of which there are three.  This will vary somewhat from region to region, but referrals are mostly made using an online referral system and the general guidelines are as follows:

Refer to:

• Specialist Orthodontic Practice. This will be where most referrals should be sent, as they are able to provide treatment for a wide range of malocclusions, mild and complex.
• Community Dental Services may be a better option for referral of some patients with physical and mental disabilities, or those with complex medical histories. Although, most specialist orthodontic practices will also be able to offer treatment to some of these patients.
• Hospital Orthodontic Department. It is best to refer complex cases that will require a multidisciplinary treatment approach into the hospital service.

So, we know which patients we are referring, and to where, but do we know when to refer?

The simple answer is all referrals for orthodontic consultations should be made when the patient is in the late deciduous and early permanent dentition.

There are, however, a few malocclusions that warrant early referral in the deciduous dentition.

Early referral when patients present with:

• Cleft lip or palate or other craniofacial deformities.
• Severe skeletal discrepancies should parents express concern.
• Advice for balancing/compensating extractions as the timing of extractions will influence the position of adjacent teeth and the need for further treatment.
• Missing or supplemental teeth to plan for space maintenance or extraction of supernumerary teeth which may be impeding the eruption of the permanent dentition.
• Severely delayed dental development to allow for monitoring of dental developmental
• History of head and neck radiotherapy or chemotherapy

Any other orthodontic issues, such as those assessed by the IOTN, can be referred at the optimal time.

Avoid referring if:

• The patient does not want orthodontic treatment. Treating such patients can be a real struggle with damaging consequences.  Patients who are not keen on having braces frequently miss appointments, damage appliances, and fail to return for treatment, risking adverse effects associated with unmonitored braces such as white decay and gum disease.

There is active disease, for example caries or periodontal disease, unless it’s for advice regarding extractions.  This is particularly relevant for first permanent molars with poor

• prognosis where consideration of the timing of extractions is paramount in influencing the best position of the second permanent molar.
• Oral hygiene is poor, as control of this once appliances are fitted becomes can be more challenging.
• The patient is too young. Most patients are best treated between the ages of 10-14 years of age when they are in the late mixed and early permanent dentition.
• A Digitsucking habit persists, as orthodontic treatment cannot be started until this has stopped.
• The patient is over 18. Whilst NHS treatment may be available for such patients within the hospital system, it is largely restricted to those with complex occlusal and skeletal discrepancies requiring a multi-disciplinary approach.

Adult Patients

There are an increasing number of adult patients seeking orthodontic treatment, purely for alignment of teeth, or in conjunction with cosmetic or prosthodontic work.

As previously mentioned, only the most complex of adult cases will qualify for NHS treatment, so most adults will receive treatment on a private basis.  Given the variety of brace options on the market, this treatment may not necessarily be provided by an Orthodontic Specialist, but I would still recommend referral for more challenging cases or those unsuitable for aligners.