Inclusion of Clinical Photographs with General Dental Practitioner Electronic Referrals of Patients with Oral Mucosal Disease to Secondary Care – A Service Review

Introduction
Vetting of referrals from GDPs requires the receiving clinician to decide how urgently the patient should be seen based on the information provided. Referrals are often brief and may not provide enough information to make an informed decision. Unclear referrals which might suggest oral cancer are upgraded for patient safety. In an e-Referral, the GDP has the option to attach a photograph. This study looks at how the inclusion of photographs in referrals to an oral medicine specialist service can improve the adequacy of the referral for triage, prioritisation, and diagnosis.

Methods
Data was prospectively collected from e-referrals over a 4 month period which totalled 367 e-Referrals. We recorded any change in appointment prioritisation at the vetting stage and the inclusion of photographs.

Results
Only 29.5% of referrals included a photograph. 5% were rejected with advice, as it was clear from the photograph that the patient did not require a secondary care appointment. 14% of all referrals were upgraded in urgency, five of which were due to concerns of malignancy. Of these, 80% included photographs, and 3 were upgraded solely based on these photographs as they showed features of possible malignancy, where the written element of the referral did not describe nor raise such concerns.

Conclusion
A good quality referral letter is the most important factor in ensuring accurate assessment and a photograph can be an excellent supplement. Including a photograph with a referral can often make up for inaccurate or insufficient written content, allowing appropriate and safe prioritisation, especially where the referrer has failed to recognise possible malignancy. Photographs can also prevent unnecessary referral upgrades, ensure an appointment is necessary and can be invaluable as a baseline comparator. Long term, it should be mandatory for photographs to be sent with an Oral Medicine referral when dentists select ‘Oral Soft Tissues’ on e-Referrals to help correctly prioritise patients, manage the patient remotely and minimise risk.