How do I refer to Special Care Dentistry?

I am writing this as I have recently been approached by clinicians and patients alike about how to access Special Care Dentistry... so here's generally how it works.

What Level of Care is the Patient?

Levels of care are referred to with most of the Commissioning Guidelines published by NHS England. They refer to the complexity of the patient, and whether they can be seen by a general dentist, one with enhanced skills (dentists with special interests for example), or Specialist/Consultant care. 

For Special Care Dentistry, these are defined as:

Level 1 - Patient to be seen in General or High Street Dental Practice

This can be as part of shared care from level 2 or 3, or on instruction from a specialist service or practitioner providing a treatment plan. 

This could be a patient who might just minimal reasonable adjustments to access the care they need, for example, a longer appointment, anxious patients who tolerate treatment with behaviour management techniques, patients with stable medical conditions who are suitable to be seen in primary care. 

Clinical teams will be able to see these patients from the education they receive as part of dental undergraduate and foundation training. 

Level 2 - Patient to be seen in the Community Dental Services (CDS), by clinicians with enhanced skills in Special Care Dentistry 

This can also be a part from shared care, but patients require additional skills to manage their additional needs. This could be cause they require sedation, domiciliary care or additional equipment such as wheelchair recliners/hoists or bariatric dental cares to access dental care. 

They also might require additional support in communication (e.g. use of Makaton, Sign language, communication aids), lack capacity to consent (therefore needing Best Interest's Decisions), more unstable medical problems or rely on others to provide their oral care. 

Level 3a/b - Patient to be seen in the CDS or hospital dental services by a Specialist or Consultant in Special Care Dentistry

This level of care is for the most complex patients, where Specialist (3a) or Consultant (3b) lead care is required. 

This might be because they have severe and complex medical issues (ASA III and above), require multi-disciplinary care (for example as part of an MDT prior to certain medical treatments), patients with challenging or unpredictable behaviours, those who require a general anaesthetic for their treatment or advanced sedation techniques or require clinical holding. 

Once you understand what level of care is required for your patient, you then need to work out what your local referral pathways are like. 

How do I Refer?

On the whole, level 1 patients are expected to be seen in General Dental Services, which are open access and do not need referrals - although the NHS dental access crisis is making it hard to find a dentist in some areas of the country. 

For level 2 care, this will require a referral to the local Community Dental Services, and similarly for level 3 care this might require again a CDS referral, but might be a referral to local dental hospital if there is one in the area. 

Local pathways and methods of referral are lead by the local NHS England dental commissioning team in conjunction with the relevant Managed Clinical Network. Some areas have a central referral system, some you refer to each service via a separate referral process. 

Referrals to the CDS and hospital dental services can be made by general dentists but also many will accept referrals from other health and social care professionals e.g. GPs, care home managers, social workers, nursing teams. In some more rare cases, some services do accept self-referrals, but these might be for certain elements of their service only (for example if they have a clinic for people who experience homelessness). 

To find out your local pathways, please consult your local dental network, but many CDS or hospital services will also have information available on their websites with referral processes. Many also will accept online referrals as well as paper based ones. 

What Information should I include?

If there is a central referral system or referral template form for the service you are referring to, please do use that, but if you are writing a referral letter, please do make sure you include the following information as a minimum:
  • Patient information and contact details (DoB, gender, address, telephone etc)
  • GP information and other medical/social care professionals involved in their care if relevant
  • What treatment has been attempted/managed in the past
  • What treatment is needed 
  • Medical history (medical conditions, medications and allergies)
  • Why they are being referred if referring onwards from level 1 or 2 care upwards
  • Any special considerations with transport/access/communication e.g. wheelchair access, transport required, interpreters, next of kin or lasting power of attorney details
  • Whether urgent or routine

Are there Private Options?

Private Special Care Dentistry activity hasn't really been captured before and is likely to be one of the smallest fields in private dentistry in the UK. Many of our patients either cannot afford to access private dental care, or in fact it is not appropriate (for example, if they need to be managed in secondary care). 

There are some practices who do offer private dental care and will see patients who fall under the remit of Special Care Dentistry - particularly for those patients who require sedation to have their dental treatment. There are also some providers who offer private General Anaesthetics but these are fairly rare. 

Private services are usually heard about by word of mouth, so getting in touch with local services and contacts would be the best way to find services or practices in your locality. 

Please do network locally to find out services in your own region.

Do leave in the comments if you are unsure of the services in your area.

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