Referral letters are the most traditional way of communicating confidential patient information between two health professionals. In the context of oral medicine, referral letters are frequently the only method by which information is transmitted between a general dental or medical practitioner and the oral medicine specialist. Additionally, the quality and the content of the referral letter is crucial to allow appropriate prioritisation of urgent oral medicine patients. Even when an oral medicine waiting lists seem long, there has always been a priority system offering immediate appointments to patients with suspected oral cancer, pre-cancer, and acute orofacial pain. Unfortunately, there have been one-too many cases where a referral letter with insufficient information led to a delay in oral cancer diagnosis, resulting in poor outcomes for the patient.
So where is this breakdown in communication taking place? While there is no recent Australian data, a UK based study demonstrated lack of time, confidence in making a diagnosis and lack of administrative support as barriers to achieving an ideal referral communication. I must acknowledge that this study was conducted in 2004. One could appreciate technological barriers such as computer facilities and secretarial support during that time. But that surely cannot remain a barrier now? Additionally, general dental practitioners also had differing perceptions on what made an ideal referral letter compared to an oral medicine specialist. Surprisingly, almost 30% of dentists did not think any description of the lesion was essential. It appears that this issue remains unchanged, as a recent study from Brazil noted 40.6% of their referrals to be of poor quality and were missing relevant clinical information. Both studies suggested increased training, guidance, and implementation of tools to improve referral quality.
So how can you ensure that your referral letter appropriately communicates with your oral medicine specialist? Include the following details:
Patient details: Name, date of birth, address, contact details
Relevant medical history
Clinical history: symptomology, time of evolution
Describe the lesion: location, size, morphology, consistency
Differential diagnosis
Send a clinical photo! – “A picture is worth a thousand words” could not be any truer
Finally, if you suspect your patient is suffering from any of the suspected conditions listed below, indicate on your referral that it is urgent and give your friendly oral medicine specialist a ring to ask for guidance!
Suspected malignancy
Severe oral pain from a suspected oral mucosal disease
Acute, severe orofacial pain, e.g., suspected trigeminal neuralgia
Acute locked jaw
Sudden onset or spontaneous development of orofacial symptoms, e.g. numb chin
If you are interested in the studies mentioned above, you can find the references below:
White, D., Morris, A., Burgess, L. et al.Facilitators and barriers to improving the quality of referrals for potential oral cancer. Br Dent J 197, 537–540 (2004). https://doi-org.ezproxy.library.uwa.edu.au/10.1038/sj.bdj.4811800
Rodrigues Camila Real Delegá, Fernandes Patrícia Maria, Santos-Silva Alan Roger, Vargas Pablo Agustin, Lopes Marcio Ajudarte. Evaluation of the quality of referral letters: experience of a Brazilian oral medicine service. Braz. oral res. [Internet]. 2021 [cited 2021 May 13] ; 35: e037. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1806-83242021000100236&lng=en. Epub Apr 26, 2021. https://doi.org/10.1590/1807-3107bor-2021.vol35.0037.