Development of positive relationships between dental faculty, predoctoral, and postdoctoral students are critical for establishing an effective referral system...

AAP Guidelines for Referring Patients in Dental Schools

Development of positive relationships between dental faculty and students are critical for establishing an effective referral system.

Background Information for Program Directors

Authors of two recent publications have suggested that patients may not be referred for periodontal specialty care in a timely fashion, or may not be receiving adequate initial periodontal therapy in general dental practices (Cobb CM, et al. J Periodontol 2003;74:1470-1474; Dockter KM, et al., J Periodontol, 2006;77:1708-1716). The Sheps Center Report (presented at the 2001 Predoctoral Educator’s Workshop) strongly implied that referral habits and attitudes regarding periodontal referrals begin to develop in the dental school environment. Dental schools should teach that periodontists are colleagues and supporters of comprehensive patient care and emphasize the value of interdisciplinary care. The American Academy of Periodontology published the Guidelines for the Management of Patients with Periodontal Diseases (J Periodontol 2006;77:1607-1611) to assist in the co-management of patients with periodontal diseases and conditions.

Development of positive relationships between dental faculty, predoctoral, and postdoctoral students are critical for establishing an effective referral system. There is a need for predoctoral dental students to understand the full range of services provided by periodontists and for developing an effective referral protocol. The positive relationship between general dentists and periodontists should begin during predoctoral dental education, and be encouraged to carry-over into private practice. The purpose of this document is to provide dental educators with guidelines for periodontal referral with an emphasis on teaching positive referral relationships in the predoctoral and postdoctoral periodontal curricula.

The referral process within a specific dental school is dependent on the clinical teaching model employed and whether the school has a postdoctoral program in Periodontology. The three most common models of periodontal clinical instruction include:

Patient referral for specialty care may typically take place at one of five time points:

Due to individual differences in treatment philosophy, goals and limitations of predoctoral instruction and training, it is impractical to establish universal criteria for periodontal referrals based upon specific periodontal findings (e.g.: probing depths, attachment loss, levels of inflammation, the presence of risk factors). Therefore, this document provides guidelines for referral based on the 3 levels delineated in the Guidelines for the Management of Patients with Periodontal Diseases, considering the periodontal diagnoses, severity of disease or conditions, contributing local and systemic factors, and complexity of patient management. These guidelines are intended to serve as a model for predoctoral and postdoctoral dental educators and should not be considered as strict standards to be universally adopted. The American Academy of Periodontology’s position is that each program should have established criteria with mechanisms for referral, when applicable, and predoctoral students, postdoctoral students and faculty be educated in referral guidelines and practices.

Referral Guideline Recommendations

Reasons for Referral

Predoctoral students should understand the reasons why a general dentist (predoctoral student) refers a patient to a periodontist (postdoctoral student or periodontal faculty) and understand how this optimizes patient care. General reasons for referral are focused on collaborative efforts to improve patient treatment and include the following:

The American Academy of Periodontology’s Guidelines for the Management of Patients with Periodontal Diseases are provided to assist in identifying patients who would benefit from timely co-management and the unique partnership that should develop between a periodontist and a referring dentist. While these Guidelines were developed for clinicians already in practice, they should be used as the foundation for referral decisions within dental schools. There are three levels of consideration for referral:

Before a periodontal referral is made, the predoctoral student should be able to properly examine patients, diagnose periodontal diseases, and understand the indications, contraindications, limitations, and expected outcomes for most forms of periodontal therapy. Depending on the clinical findings and diagnoses, the predoctoral student may treat certain periodontal conditions with appropriate guidance. As a patient is referred, the student should still be familiar with and understand the implications of the patient’s periodontal conditions on overall prognosis and treatment. He/she should be able to interact with the postdoctoral student or periodontal faculty member in an informed manner.

Exposure of Dental Students to the Full Scope of Periodontal Therapy

Although periodontal therapy performed by predoctoral students is primarily nonsurgical, the exposure of predoctoral students to surgical therapies through assisting, laboratory exercises, interactive case presentation seminars, and possibly performance of surgical procedures will increase the predoctoral students’ awareness of the indications, contraindications, expected outcomes, limitations and complications of the delivery of complex periodontal care. This in-depth familiarity with complex periodontal care will assist the predoctoral student in making the proper referrals in dental schools and eventually in private practice.

Predoctoral and Postdoctoral Student Relationships

Developing positive relationships between predoctoral and postdoctoral students is important to the referral process. These relationships may be enhanced through direct postdoctoral student input into the predoctoral education process through clinical or classroom teaching, surgical assisting, interactive seminars, study clubs and/or lunch and learn sessions. It is essential that postdoctoral students take time and make the effort to educate predoctoral students and that they develop positive working relationships that will carry-over to private practice. The basis of this relationship should focus on “patient centered care”.

Teaching Referral Practices Recommendations

Communication of Guidelines and Process

Predoctoral and postdoctoral students should receive training in referral practices that include criteria for referral and the process of making or accepting a referral. This training should be integrated into the predoctoral didactic curriculum, case presentations, comprehensive treatment planning and during discussions at periodontal re-evaluation following initial therapy. Dental faculty in other disciplines should be informed of the referral guidelines and process. Additionally, referral patterns may be enhanced through in-service programs with general dentistry faculty. Workshop topics may include clinical examination, radiographic interpretation, periodontal diagnosis, comprehensive treatment planning, periodontal surgery and surgical outcomes.

Instruction Regarding Referral Process

Guidelines for referral practices should include effective communication between predoctoral students and postdoctoral periodontology students or periodontal faculty. Communications should be modeled after private practice. For predoctoral students, communication includes reasons for referral and pertinent patient information (e.g.: treatment history, periodontal findings, factors that modify the course of periodontal disease, charting and radiographs and treatment planning). As part of the referral/consultation interaction, predoctoral students should be required to articulate a patient’s clinical findings, problems, restorative treatment plan and other relevant information. Referral forms specific to the periodontal findings, periodontal reevaluation and planned periodontal surgery would facilitate the process.

Postdoctoral students should be given training on appropriate patterns of referral. For example, postdoctoral students should not refer a patient to a different predoctoral student or general dentist unless the patient’s dental health is in jeopardy because of the student or dental negligence is evident. Precluding lack of patient compliance, periodontal treatment should be completed in a timely manner and documented in a written narrative. This narrative should include clinical/radiographic findings, diagnosis, prognosis, treatment, treatment outcomes and maintenance care. Suggested educational experiences for predoctoral and postdoctoral students should include utilization of written referral communications, similar to referral forms and letters used in practice.

Potential Mechanisms For Instruction in Periodontal Referrals

Possible formats for instruction include: lectures/seminars in referral criteria and processes, interactive treatment planning seminars, case presentations that include interdisciplinary treatment and clinical instruction that models optimal patient care. Referral practices cannot be exclusively taught in the classroom; the interactions on the clinic floor between general dentists, specialists, and dental students will provide an excellent example for predoctoral students. Periodontal faculty and postdoctoral students may utilize consultation-type interactions to teach and reinforce the referral process. Stronger relationships for predoctoral and postdoctoral students may be developed through models that simulate “best practices” interactions between general dentists and periodontists. There are several possible formats, depending on the institution’s teaching model and physical environment. One option might be to pair a postdoctoral periodontology student with a group of predoctoral dental students. The predoctoral students would then become part of the referral base for the postdoctoral student. Interdisciplinary teaching in small group problem-based seminars may also promote positive relationships. Interactive case presentations would emphasize the benefits of the consultation-referral process.

Involvement of Private Practitioners

Private practice part-time faculty should be a strong asset in the educational process. Participation by private practice periodontists and general dentists who have had effective referral relationships may be helpful in presenting models of interaction from a private practice perspective.

Explanation of Terms

May

A choice to act or not; indicates freedom or liberty to follow a suggested alternative.

Should

A highly desirable direction but does not mean mandatory.

Must

Used to express a command; indicates an imperative or duty. This term does not appear in the document and is provided as a comparison to the terms “may” and “should”.

Comanagement

A shared responsibility for patient care between a periodontist (postdoctoral student or periodontal faculty) and referring dentist (predoctoral student). This patient management may consist of consultation and/or treatment.

Reevaluation

Assessment of a patient’s periodontal status and risk profile after therapy to be used as a basis for subsequent patient management.

Deteriorating risk profile

Adverse changes in risk factors/indicators suggestive of disease onset or progression.

Disease Definitions

For disease definitions such as Severe Chronic Periodontitis, Aggressive Periodontitis, and Acute Periodontal Conditions, please refer to volume 4 of the Annals of Periodontology or information on the classification of periodontal diseases on the AAP Web site.

Peri-Implant Disease

Chronic inflammation and/or bone loss around dental implants that may influence implant status.

Periodontal Inflammation

Most periodontal diseases including chronic and aggressive Periodontitis are inflammatory diseases. Chronic Periodontitis has an infectious etiology from the endogenous plaque biofilm. This type of opportunistic infection results in a chronic release of inflammatory cytokines, prostaglandins, and destructive enzymes from neutrophils and mononuclear cells in the periodontium. The ensuing chronic inflammation in the tissue is what leads to the pathologic anatomic changes clinically detectable as periodontal pockets and alveolar bone loss. Furthermore, some microorganisms of the biofilm and inflammatory mediators from the affected tissue may adversely affect systemic chronic inflammatory diseases and pregnancy outcomes.

Significant Root Surface Exposure

Gingival recession of sufficient magnitude that results in the loss of tooth structure, sensitivity, esthetic concerns, or attachment loss.

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