Some met. The interventions that were carried out

Some re-audits have found improvements in the number of patients being referred on time when some action is taken. Following intervention, in a re-audit carried out in the Orthodontic Department of Pinderfields Hospital, a 20% increase in the number of patients being referred on time was observed however the authors admitted the target of 90% of referrals being appropriately timed was still not being met. The interventions that were carried out following the Orthodontic Department of Pinderfields Hospital first audit cycle included an e-learning package and delivery of local lectures on the subject. The authors state an hour of continued professional development was available if a questionnaire was filled in, however, only a 20% response rate was seen highlighting the difficulties of implementing change in both primary and secondary care. (Hyde, Barber and Spencer, 2015) The re-audit carried out in Royal Surrey County Hospital NHS Foundation Trust found that the local education programme that had been introduced following an audit on referral times in 2002 had no lasting effect. The programme involved reminding local practitioners of the current guidelines and making them aware of the findings. 45 percent of patients in the original 2002 audit were referred late, compared to 76 percent in the 2016 re-audit. The authors of both re-audits have made a number of recommendations to improve patient referral times and as a result, patient outcomes. The authors suggest that interceptive orthodontics and canine ectopia should be incorporated into dental foundation training days, referring clinicians should be updated with the audit results and should be reminded of the current guidelines for referral and they also recommend adding a reference to canine palpation in paediatric exam proformas/templates so that clinicians are reminded to do this. The implementation of electronic referral system has been put forward, the authors suggest that this may prompt clinicians to assess for impacted canines. Enforcing guidelines and the implementation of delivery of education and training programmes to GDPs with the help from local area teams may help improve referral times. Education and training such as CPD courses in assessing for ectopic canines and the importance of appropriately referring those patients with an ectopic canine may be beneficial and providing feedback to those clinicians who frequently refer patients late will benefit both patients and clinicians. (Hyde, Barber and Spencer, 2015; Patel and Taylor, 2016) Conclusion Of those patients studied, 17.3 percent with ectopic canines were found to be referred on time. Meaning that the remaining 82.7 percent that were referred late at an average age of 14.9 years, 2.9 years later than the referral age suggested by the Royal College of Surgeons. This delay reduces the chance for early interceptive techniques which may remove the need for more costly, lengthier treatment. The reduced need for these more complex treatments would not only be preferred by patients but reduce some of the burden currently on our health resources.  This large percentage of patients being referred late is a similar percentage to those found in other parts of the UK, however with some implementation of e-learning programmes and local delivery of lectures the number of those being referred appropriately has increased. The use of paediatric exam templates that contain a reference to canine palpation, implementation of online referral forms, the inclusion of interceptive orthodontics and importance of appropriately referral in dental foundation training and CPD for general dental practitioners on the subject are just some of the recommendations put forward to attempt to improve the number of appropriately timed referrals. It is important to remember that canines erupt between 11 and 12 years of age and it should be suspected that a canine is ectopic if the crown is not palpable in the buccal sulcus by the age of 10-11 years, the position of neighbouring teeth implies malposition or there is an asymmetric pattern. Reflection/Future work The authors believe that GDPs in the area should be made aware of the results of the audit. The guidelines on management of ectopic canines should be highlighted and further change may also be beneficial such as the teaching of canine ectopia in dental foundation training and CPD on the subject for general dental practitioners, implementation of online referral forms and the use of paediatric exam templates that contain a reference to canine palpation. Following the implementation, the authors recommend that a re-audit should be carried out. The authors suggest a re-audit in 2 years’ time observing the percentage of appropriately timed referrals of patients with ectopic canines would be beneficial to determine whether any implementation has had a positive impact. The follow-up of the patients seen in the audit would be interesting. Comparing the complexity and length of treatment of those referred late compared to those referred appropriately and determining whether this delay in referral time has had an effect on any treatment given would be intriguing. The average time between being referred and being seen at the hospital may also be something worth investigating in the future as this in itself may have an impact on the delay and in turn affect treatment. This could be re-investigated after some time to determine whether waiting times are improving or worsening.