Oral Surgery

The specialty of Oral Surgery deals with the diagnosis and management of pathology of the mouth and jaws that requires surgical intervention, but where cancer is not suspected.

Referrals tend to be from GDPs rather than GPs, and the following guidance reflects that.

Oral Surgeons manage treatment of children, adolescents and adults, and those who are dentally anxious or medically complex. Oral Surgery care is provided by both Oral Surgeons and Oral & Maxillofacial Surgeons as the clinical competencies of these two specialties overlap.

All those suspected of having cancer must be referred to Oral and Maxillofacial Surgery.

Oral surgery is delivered on two sites in NHS Lothian:

Edinburgh, Mid- and East Lothian patients – Oral Surgery at the Edinburgh Dental Institute. SCI Gateway access is via Lauriston (Oral Health). Please note that care may be delivered within the Public Dental Service and the site may vary with NHS Lothian.
West Lothian patients – refer to Oral Surgery at St John’s Hospital, Livingston, where patients are managed by the Oral & Maxillofacial Surgical team – Oral and Maxillofacial Surgery.

Associated specialties are:

Oral Health Service

The Oral Health Service (OHS) delivers specialised oral health care, leads oral health improvement for the population of Lothian and provides excellent training of oral health professionals for the future

Oral Medicine

Oral medicine is the specialty concerned with the diagnosis and non-surgical (medical) management of patients who suffer chronic, recurring or medically related illnesses of the oral and maxillofacial region. This specialty treats medical conditions affecting the oral mucosa, salivary glands, nervous system and systemic conditions which involve the oral and maxillofacial region

Oral and Maxillofacial Surgery (OMFS)

OMFS deals with the diagnosis and management of benign and malignant diseases affecting the mouth, jaws, face and neck. The team at St John’s Hospital delivers the only OMFS service for NHS Lothian and does so for patients of all ages, including children.

C.M & L.B – 12-10-26

Urgent Suspicion of Cancer.

Patients with lesions in their mouth considered urgent suspicious of cancer should be referred directly to the OMFS service at St John’s Hospital using the specific SCI Gateway pathway. They should not be referred to Oral Surgery but to Oral and Maxillofacial Surgery.

Emergency referrals

If a GP or a dentist needs to access an emergency referral for a patient, please contact either:

Oral Surgery – Edinburgh Dental Institute – 0131 536 2221. Calls will be accepted Monday to Friday (9:30 – 12:00 and 1:30 – 16:00). Clinicians only. Calls from patients will not be accepted via this phone.
Oral and Maxillofacial Surgery – via St John’s Hospital switchboard. 01506 523 000.

Patients with a dental infection with systemic involvement or significant facial swelling should be referred to OMFS as an emergency – please phone the specialty directly.

Please note that it remains the responsibility of the referrer to provide or secure any necessary treatment or advice (including emergency / urgent care) until the patient is assessed by the service.

These details are not for use by patients who should contact their dentist or GP if they need help.

Urgent referrals

Conditions that may be prioritised for urgent referral:

Delayed healing of tooth sockets
Suspected established MRONJ
Large cystic or bone lesions
Fractured tuberosity
Displaced roots / teeth
Oro-antral communication
Impacted canines with adjacent tooth resorption
Minor oral surgery for medically complex patients needing timely intervention.

Routine or Urgent Referrals via Sci Gateway:

Edinburgh, Mid- and East Lothian Lauriston Oral Health Oral Surgery.
West Lothian St John’s Oral Surgery see Oral and Maxillofacial Surgery

Who to refer – summary (detailed account follows below):

The following conditions are managed:

Third molar assessment and surgery
Surgical removal of buried roots, failed extractions or fractured retained roots not amenable to non- surgical removal
Assessment and management of ectopic teeth (including supernumerary teeth)
Surgery relating to Orthodontic Treatment to facilitate orthodontic treatment plan such as exposure of ectopic teeth
Assessment and management of intra-oral benign soft and hard-tissue lesions, including cystic lesions, with no suspicion of cancer
Diagnosis and management of benign soft tissue lesions, with no suspicion of cancer
Management of suspected or diagnosed oro-antral communications or fistulae, tuberosity fractures or teeth and roots displaced into the maxillary antrum
Medication related osteonecrosis of the jaw (MRONJ)
Non-surgical management of temporomandibular joint (TMJ) disorders’
Management of infections of the orofacial region including localised dental abscesses
Management of post-operative bleeding.

Who to refer – details:

1. Third molar assessment and surgery

Third molar assessment and surgery where surgical intervention is indicated according to national guideline, please see guidance for information regarding appropriate referral Third Molar Guidance. Erupted non-surgical third molars with radiographic evidence of a potentially intimate relationship with the respective inferior alveolar canal can be referred. Please manage acute dental problem in line with guidance SDCEP Acute Dental Problems and document acute management in referral Acute Dental Problems

Please include relevant radiographs. A minimum of a periapical radiograph, bitewing radiograph or OPT (OPT if available) or reason why this was not possible must be included. Bitewing radiographs are valuable for third molar assessment, please include these where relevant and available.

Clinical information specific to third molars must be included with your referral and this includes (where relevant):

Eruption status
Caries status of third molar, or other adjacent teeth
Frequency of symptoms
Angulation
Probing depth to mandibular second molar or adjacent tooth
Considered differential diagnoses, eg. TMD
Presence of opposing upper third molars.

2. Surgical removal of buried roots, failed extractions or fractured retained roots not amenable to non surgical removal

Routine extractions should be carried out in general dental practice. They may be referred in certain circumstances. We do not accept routine extractions in our service, and this includes teeth and roots that are amenable to simple elevation, and extractions based on the need for anxiety management. Complicated extractions with anticipated difficulty due to extent of disease, local anatomy or associated pathology will be triaged on an individual referral basis and may be returned. Please provide all relevant supporting information with the referral.
Failed extractions must include a relevant radiograph (post-extraction) and description of the failed procedure and the date of the procedure.
Please include information relating to whether a claim has been submitted where applicable, in line with GDS terms and conditions.

3. Assessment and management of ectopic teeth (including supernumerary teeth)

Clinical information should be included including eruption status, caries status, assessment of adjacent teeth, symptomology.
If the referral relates to the orthodontic interface, we require a copy of the treating orthodontist’s treatment plan / letter to triage the referral and the contact details of the general dental practitioner (GDP).
Please note that patients under 16 should be referred to Paediatric Dentistry initially Paediatric Dentistry.

4. Surgery relating to Orthodontic Treatment to facilitate orthodontic treatment plan such as exposure of ectopic teeth.

Referral should include orthodontic treatment plan including orthodontist details, any further dental treatment or extractions being carried out and any clinical prioritisation or urgency documented (such as resorption).
We require a copy of the treating orthodontist’s treatment plan / letter to triage the referral and the contact details of the patient’s general dental practitioner.

5. Assessment and management of benign intra-oral benign soft and hard-tissue lesions, including cystic lesions

The diagnosis and management of pathology of the mouth and jaws that requires surgical intervention, but where cancer is not suspected.
Consider referral criteria for Oral Medicine, and Oral and Maxillofacial Surgery before making your referral.
Include relevant clinical description and attach relevant radiographs and photographs.

6. Diagnosis and management of benign soft tissue lesions

This includes benign soft tissue overgrowths such as fibroepithelial polyps, denture hyperplasia, drug-induced gingival hyperplasia, mucocele, small vascular lesions or squamous papillomas
All referrals from dentists must have accompanying photographs attached and radiographs if appropriate; ideally referrals from GPs should include photographs too
For referrals for assessment of oro-mucosal disease beyond this please go to Oral Medicine
Where there is a suspicion of cancer, these should be directed via the Urgent – Suspicion of Cancer (USOC) pathway Oral and Maxillofacial Surgery

7. Management of suspected or diagnosed oro-antral communications or fistulae, tuberosity fractures or teeth and roots displaced into the maxillary antrum.

Consideration will be given to surgical removal of tooth / teeth / root(s) that may involve access into the maxillary antrum.
Referrals for traumatic Oro-Antral Communication (OAC) or fractured tuberosity may be considered urgently.
Referrers may contact the department on 0131 536 2221 for urgent advice if required. CLINICIANS ONLY can use this advice line. A referral via SCI Gateway is also required.
If a referral is being made, then please do so via SCI gateway in addition to the above.

8. Medication related osteonecrosis of the jaw (MRONJ)

Dentoalveolar surgery for patients requiring a multidisciplinary approach and for assessment and management of established MRONJ:

This does not include patients at lower risk of MRONJ. Please see SDCEP for appropriate management of these patients in primary care – Oral Health Management of Patients at Risk of Medication-related Osteonecrosis of the Jaw (SDCEP). Routine extractions in patients at lower risk of medication related osteonecrosis of the jaws (MRONJ) should be managed in general dental practice SDCEP MRONJ
If an extraction socket is not healed at 8 weeks and MRONJ is suspected, please refer with the relevant clinical information, clinical photographs and radiographs (pre and post extraction).
Patients at increased risk of MRONJ requiring dentoalveolar surgery, or dental extraction will be considered on an individual basis (development work here – under review).

9. Non-surgical management of temporomandibular joint (TMJ) disorders

Assessment and management of temporomandibular joint dysfunction in line with national guidance RCS Eng TMD Guidance
Consider and exclude dental causes for symptoms by a dentist (this information should be shared in the referral including relevant images/x-rays), and evidence of supportive self-management followed prior to the point of referral in line with published national guidance.
Patients presenting to their GP should be referred to their dentist in the first instance.
Any red flags requiring urgent investigation should be referred appropriately immediately to the appropriate service.

Please note that the Oral Surgery, Oral Medicine or OMFS services do NOT offer Botulinum Toxin injections for the management of TMJ dysfunction currently.

10. Management of infections of the orofacial region including localised dental abscesses.

Please follow available guidance on SDCEP SDCEP Acute Dental Problems initially.
Referrals will be considered on an individual basis.
Consider utilising the urgent triage telephone line.

11. Management of post-operative bleeding.

Please follow available guidance on SDCEP SDCEP Acute Dental Problems initially.
Referrals will be considered on an individual basis. Consider utilising the urgent triage telephone line.

Who not to refer:

Where there is a suspicion of cancer, these should be directed via the Urgent – Suspicion of Cancer (USOC) pathway Oral and Maxillofacial Surgery

Management of benign or malignant tumours of minor or major salivary glands or obstructive disease of major saliva gland, please direct these patients to Oral and Maxillofacial Surgery

Patients with complex medical history requiring Oral Surgery input. We do not accept patients with medical complexity for routine dental extractions. However, patients who require a multidisciplinary approach between medical and dental teams to facilitate Oral Surgery care may be considered and please review referral guidance for the associated specialties before making referral.

Surgical management of periradicular pathology / surgical endodontics. Consideration for periradicular surgery in the absence of cystic pathology will not be considered in the Oral Surgery service. Periradicular surgery will be considered in cases where there is apical pathology that requires histo-pathological assessment. Please consider Restorative Dentistry.

Temporomandibular joint (TMJ) dysfunction where supportive self-management has not been provided in line with national guidance RCS Eng TMD Guidance

Routine extractions in otherwise healthy patients.

Routine extractions in patients who are at lower risk of MRONJ SDCEP MRONJ

Routine extractions where the patient is on a single anticoagulant or where the INR is maintained below 3.5 (see SDCEP guidance on Management of Dental Patients Taking Anticoagulants or Antiplatelet drugs)

Patients with dental problems that require restorative treatment. RefHelp guidance for ‘Oral Health Service: Restorative Dentistry.

Patients for whom a purely radiographic opinion is requested. Please direct these to Radiology via SCI Gateway

Patients for placement of dental implants. Internal referrals may be made for Oral Surgery input into multidisciplinary care for priority group patients in line with guidance from associated specialties Restorative Dentistry.
Simple dental extractions in anxious patients. Please consider referral to the Adult Anxiety Management Service in the Public Dental Service.

How to refer:

Referrals should be made via SCI Gateway.
Referrals must contain all relevant clinical information, in addition to the patient’s medical and social history.
Any referral relating to soft tissue lesions from General Dental Practitioners require a clinical photograph. Referrals from General Medical Practitioners should ideally have clinical photographs attached, as this allows us to safely and appropriately triage these patients to the correct pathway. The team’s experience is that photos can help identify lesions where cancer needs excluding and those patients then urgently redirected to OMFS. They may be taken by the patient if there is no access to clinical photography. This allows us to safely and appropriately triage these patients to the correct pathway.
Referrers should include relevant radiographs / charts / and clinical photographs in their referrals. These should be sent as an ‘attachment’ in SCI Gateway, appropriately labelled. If you have images exceeding the maximum file size or have relevant non digital images, please use an alternative option. The maximum file size is 2MB, sum of all attachments, 5MB. Advice can be sought from our Pathways Team via loth.edireferrals@nhs.scot.
For sharing Cone Beam CT Scans (CBCT) please contact our Pathway Team (loth.edireferrals@nhs.scot, 0131 536 1129). Imaging reports for CBCT should be attached to the referral. All imaging must be labelled appropriately, or it will be returned (demographics, date image taken).
Where a practitioner works outwith the NHS then the referral should be sent via email to loth.edireferrals@nhs.scot.
Once received, your referral will be triaged and directed to the appropriate part of the service with the appropriate prioritisation. Please note where incorrectly appropriated referrals are made this can result in a delay in the triage process.
Where referral criteria for the service have been met, patients will be offered an appointment. Where referral criteria for the service have not been met, a letter will be sent to the referrer with an explanation. It is the responsibility of the referrer to ensure that the patient is informed of this returned or redirected referral, and the clinical responsibility remains with the referrer.
Allocation of appointments will be dependent on individual referrals and assessment appointments may initially be offered face to face or remotely via telephone or video consultation using near me technology.

Referral destination – please refer via SCI Gateway:

There is a single point of entry for patients in Edinburgh, Mid- and East Lothian via Lauriston Oral Health Oral Surgery.
West Lothian patients should be referred to St John’s Oral Surgery via Oral and Maxillofacial Surgery

Charges

Some Oral Surgery care is delivered under General Dental Service (GDS) terms and conditions with strict adherence to the Statement of Dental Remuneration (SDR)
Therefore, NHS fees will apply to such treatment (unless the patient is entitled to free dental care)
This applies to all postcodes
If your referral relates to a previous failed extraction(s), please state clearly if you have already claimed for the attempted extraction(s).