Making An Orthodontic Referral.
When should a Dentist refer for an Orthodontic assessment?
Most patients are suitable to start orthodontic treatment when the permanent teeth are erupted. However there are some cases when you are advised to refer early. Interceptive treatment and functional appliances may be appropriate to correct or prevent the malocclusion from getting worse.
When to refer early?
- Severe skeletal problems, including those where functional appliances may be indicated in the late mixed dentition stage of dental development.
- Patients with unerupted teeth and of doubtful prognosis, especially impacted maxillary canines.
- Uncertain choice of extraction patterns.
- Where there are anterior or posterior cross-bites with displacements of greater than 2mm.
- Severe Class II/1 malocclusion with signs of previous trauma
- Poor long-term prognosis of first molars in a crowded dentition
- Cleft lip and palate and craniofacial anomalies
Other referrals in the deciduous or mixed dentition:
- Children with special needs
- Severe Class III in the mixed dentition
- Lack of palpable maxillary canine bulge buccally at 10-12 years of age indicating potential impaction of canine
- Delayed eruption of permanent teeth
- Hypodontia, supernumerary
- Low/ thick frenum obstructing eruption of teeth or causing diastema
- Infraoccluded deciduous molars with associated tipping of adjacent teeth
- Severe crowding in the incisors
Types of problems in the permanent dentition:
All other malocclusions not treatable within the competency of the dentist.
- Those requiring multidisciplinary input such as Orthognathic surgery, periodontally compromised patients etc.
- Those requiring complicated biomechanics and the use of temporary anchorage devices.
Dentists can refer to Orthodontic Clinical Practice Guidelines (CPG) from the Ministry of Health Malaysia website or from the recognised global professional bodies such as the Royal Colleges UK.
- Orthodontic management of developmentally missing incisors
- Management of unerupted maxillary incisor
- Management of anterior crossbite in the mixed dentition
- Management of the palatally ectopic canine
When is it unnecessary for an orthodontic referral?
Orthodontic treatment is not for everyone. A good guide is the index of Orthodontic Treatment Needs (Brooke and Shaw, 1989). The IOTN is an objective and reliable way to select those children who will benefit most from treatment and is a fair way to prioritise limited resources. However, there are occasions where an orthodontic referral is not appropriate. These include:-
- Very young patients in deciduous dentition with no obvious signs of malocclusion
- Uncooperative/unmanageable patients who refuse to wear braces
- Those with poor oral hygiene, active caries, rampant caries, periodontal diseases
- Parafunctional non-nutritive habits like thumb/digit/pacifier sucking. Try to encourage your patient to stop these habits with persuasive and simple conventional techniques before referring for orthodontic treatment. If these the problem persists and the parents are concerned, do refer for Orthodontic assessment and due intervention.
Where can I refer for orthodontic assessment/treatment?
This will depend on the gravity of the problem and your local referral arrangements/network. You may refer to this MAO website for a list of credentialed Orthodontists in all the various states in Malaysia from the private, government and academia sectors accordingly. Alternatively, you may get information from the Ministry of Health or your local Health Community Dental Clinics for details.
- ALL patients are eligible for routine dental assessment and treatment in government primary care clinics. You may refer the patient to the primary care clinics first or alternatively refer directly to the orthodontic clinics or dental specialists in Hospitals. Appropriate charges are applicable.
- For referral to government Orthodontic clinics, patients should be below 18 years. Patients over 18 will usually only be accepted for orthodontic treatment if they have a complex occlusal and skeletal problem requiring multidisciplinary care. These cases should be referred to the Hospital Specialist clinic. Appropriate charges are applicable.
- Children with physical or mental handicap, special needs, growth-related problems, cleft lip and palate, associated surgical problems should be referred to the Specialist clinics in Hospital for consultation and further management where necessary.
How do I make a Referral?
These tips are intended to facilitate your patients for an efficient, stress-free appointment when making an orthodontic referral and help the attending clinician to better diagnose and plan management of the patient.
Please include in your referral letter:
- Details of previous dental/orthodontic treatment; if there has been trauma to anterior teeth, long-term prognosis of carious teeth, filled teeth, endodontically-treated teeth
- Relevant medical and medication history. Please advise the patient to bring along any letters from their physicians.
- Stabilised dentition; To help your patient get appropriate treatment early please ensure your patient has good oral hygiene and is caries/periodontal disease free.
- Inform your patient the purpose of the referral and ensure the patient understands and is willing to undergo orthodontic treatment
- Special investigations; If you have taken recent relevant radiographs please include these with the referral to avoid unnecessary overexposure to radiation. If the radiographs are in digital form, a copy is adequate. (From medicolegal standpoint, all records belong to the patient and can be released to the patient with prior consent)
- Urgency; If you think the patient needs to be seen urgently please mention why in the referral letter. This will facilitate your patient to an early appointment
Please be aware that although most government orthodontic clinics in Malaysia have a ‘waiting list’ for routine fixed appliance therapy, priority is given to patients with cleft lip and palate, dental anomalies, functional and skeletal problems. The Index of Orthodontic Treatment Need (IOTN) is used by all dental officers in government dental clinics as a referral guideline and prioritisation. Treatment is eligible only for those presenting with IOTN Dental Health Component of DHC Grade 4 & 5 and consultation for DHC Grade 3 and above.
What are the options for referring adults or those with very mild malocclusion?
Many adults are now seeking orthodontic treatment and those patients with very mild malocclusion may be prompted to wear braces as their dental awareness heightens. This may be compounded by peer and social pressures as it is not uncommon in our society that braces may be regarded as a status symbol or fashion fad.
- Adults and those with mild malocclusions for purely aesthetic correction are usually not eligible for treatment in government orthodontic clinics. They may be referred to private clinics with qualified orthodontists who can offer a wide range of services.
- It is never too old to have orthodontic treatment provided the overall oral health is good and the patient maintains a good oral hygiene, has sufficient teeth and supporting alveolar bone to consider orthodontic treatment as part of comprehensive treatment goal.
- It is socially acceptable to wear braces at any age especially with current aesthetic orthodontic appliances which are almost ‘invisible’. Some of the aesthetic appliances available include clear brackets on the labial surfaces of the teeth, tooth-coloured wires, lingual appliances attached to the lingual or inside surfaces of teeth and removable clear aligners. However not all cases are suitable for these appliances. Your orthodontist will advice you on the appropriate choice of treatment and appliances.
- Some adults may have a compromised dentition due to loss of teeth, periodontal disease or lack of alveolar bone support. Treatment can be challenhing and costly due to the presence of crowns and bridges which may need removal or restoration before and after orthodontic treatment.
- Your dentist may recommend adjunctive orthodontic treatment as a means of facilitating the construction of fixed and removable prostheses or tooth implants and for the long-term health of your existing dentition. Orthodontic treatment can upright teeth and create space to improve the insertion of dentures, crowns and bridges and implants.
- Limited specific orthodontic treatment is an excellent way to resolve spacing and drifting of teeth due to periodontal disease or early loss of teeth. This may reduce unnecessary loss of tooth structure with construction of crowns and bridges for a more stable long-term outcome.
Adults with more complex occlusal and restorative problems may be treated in combined multidisciplinary clinics in government hospitals or/and the private sector. Most clinics have a ‘waiting list’ and priority is subject to the severity of the problem.
Malaysian Association of Orthodontists
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