How to Refer

Referral Guidelines

If the clinical examination reveals any suspected mucosal disorder, and particularly if cancer is suspected, the patient should be referred to a specialist in Oral Medicine, Maxillofacial Surgery or to a Stomatologist. To allay fears at this stage the dentist should be sensitive to the words used to describe what was observed, and explain that it is best to obtain a second opinion from a specialist.

Referrals should be categorised as routine, prompt or urgent.

Of course if cancer is suspected the referral must be marked “Urgent” so that the hospital can prioritize this referral.  In the UK, under NICE guidelines such referrals are placed on the “2 week wait programme” available for this purpose so that the waiting period to see a specialist within NHS is less than 2 weeks.

Several oral conditions fall under the category of urgent referral of suspected head and neck cancers; referred to as NICE (or SIGN, in Scotland) guidelines in the UK (see below). The guidelines for referral of patients suspected with oral cancer or potentially malignant oral disorders may differ within European Health Care Systems.  Dentists must be familiar with the local hospital and country guidelines.

Oral Cancer

A dentist or a family physician may suspect cancer if a new ulcer or a growth (for which there is no obvious cause) has not healed or responded to simple treatment within 2-3 weeks.  The full list of conditions that require urgent referral from a dentist is:

  • ulceration of oral mucosa persisting for more than 3 weeks

  • oral swellings persisting for more than 3 weeks

  • red or red and white patches of the oral mucosa

  • unexplained tooth mobility not associated with periodontal disease

  • non healing tooth socket for any unexplained reasons

  • ear pain without evidence of local ear disease

  • unresolving neck masses (persisting for more than 3 weeks)

Top three are considered cardinal signs of oral cancer. The NICE and SIGN guidelines also refer to other symptoms that fall under Head and Neck Cancer Urgent referrals eg. Stridor, horseness, dysphagia that should be referred urgently to an ENT unit.

Potentially malignant disorders (OPMD) that should be referred to a specialist following a mucosal examination include:

  • leukoplakia

  • erythroplakia

  • erythroleukoplakia

  • submucous fibrosis

  • lichen planus

  • discoid lupus erythematosis

  • actinic keratosis of the lips

Each of these conditions and their clinical presentations are given here and are further illustrated in the atlas. Of these presentations, erythroplakia and erythroleukoplakia (red and red & white patches) should be referred urgently (see above) because some may have already become malignant. Others should be referred as \’prompt referrals\’.

The referring practitioner should inform, the patient that at a hospital visit, a small piece of tissue may be removed under local anaesthesia, referred to as a biopsy,  in order to confirm the health or otherwise of the mucosa. A good description of what was observed should be included in the referral letter and if possible an accompanying photograph and a diagram marking the area of interest on a mouth map.

Desirable information to include in a referral letter are:

Referral Proforma (en)

* The practitioners often use the word ‘lesion’ to denote any clinical findings noted. It is recommended that the term “lesion” should not be used to refer to the clinical findings. It is best to describe what was discovered using the features listed on the right hand column.

This is the end of the How to refer module, please select the next module to continue through the guide.

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