ReferralRight: dental clearance referrals that come back

The arithmetic

28Median days from dental consultation to the start of radiation

133Days that same interval reached at the far end of the range

356Patients in the series, at one centre, all referred before radiation

52%Of the patients who needed a second look had inadequate follow-up

The first three figures are one interval across the whole series, measured from consultation. The median lands at twenty-eight days, which is why this never reads as a crisis on paper, and the same interval reached one hundred thirty-three. The spread is the problem, not the median. The fourth figure is narrower and it is the one that should worry a program: among the twenty-nine patients who needed extended healing or repeat visits, the authors recorded follow-up as inadequate in fifteen. Their own conclusion is that most patients cleared within expected timelines and a minority experienced clinically meaningful delays, which they link to prolonged healing and inadequate follow-up. The study is descriptive and attributes nothing to the return leg. What it names is the second look as the modifiable bottleneck, and that is the part nobody currently measures.

Why it does not work today

The outgoing leg of a dental clearance referral is well defined. Someone composes it, someone sends it, and it reaches a dental office. The return leg is not defined by anything. Every clearance referral is a one-way referral, and it is one-way by design rather than by accident.

There is a second failure underneath that one, and it is larger. Clinicians report referring almost always. Measured in claims data, about one in nine at-risk patients was actually seen. The referral that never happened leaves no trace anywhere. Nothing about chasing a fax is clinical. That hour belongs to a patient.

Self-reported referral rates come from a survey of 158 urologists in Switzerland, Germany and Austria (Calderaro 2023, PMID 36675567). The completion figure is 11.1 per cent of 15,357 patients on bone-modifying agents in Korean claims data, rising from 4.4 per cent in 2007 to 16.7 per cent in 2019 (Lim 2024, PMID 38566103). These are different cohorts on different continents and are not a paired measurement. They are reported separately here for that reason. A 2026 review of the same territory records pre-treatment dental evaluation as an underutilized step (PMID 42516487).

No format

No CMS, ADA, HL7, or X12 standard for the dental clearance response has been adopted by CMS, required for payment, or put into general use. The ADA's own Medicare referral form reduces the answer to a single checkbox reading "Written or Faxed Report from Dental Office / None."

No addressee

The referral names a practice. The answer comes back to whoever happens to pick up the fax. Nobody is accountable for arrival, which is why a case can sit for weeks without anyone being at fault.

No clock

The clinical deadline exists in the oncologist's head and in the radiation schedule. It is not attached to the referral, so nothing anywhere knows the case is overdue until someone thinks to ask.

How a case closes

The outbound leg is solid and it works. The return leg is the one nothing defines, so it is the one we make someone's job.

The referral goes out

Fill in the patient, the procedure, and the date the answer is needed, then sign it. It goes to the dental office by whatever channel already reaches them, which today is usually fax, with no portal for them to log into.

The dentist answers

A link and a date of birth in a browser, or a fax sent straight back. No account, no software, no install, nothing for their IT to approve.

Both sides hold the record

The answer is attached to the case and both sides hold the same signed PDF, with the time it arrived recorded on it. The clock is visible the entire time, and so is who is waiting on whom.

Nothing above requires an integration. Not on day one and not ever. A hospital that later wants this inside Epic can build the interface, and some will, but the loop runs without it and without anything to install.

Free, permanently, for every party on the loop. The coordinator does not pay, the dentist does not pay, and the patient does not pay.

What lands in the chart

One page, signed by the dentist, with four timestamps that make turnaround a fact rather than a recollection.

On the record	Who sets it
Referred	The coordinator, at composition
Received	The dental office, on open
Responded	The dentist, on answer
Date the answer was needed	The coordinator, from the clinical schedule

On the record

Who sets it

Referred

The coordinator, at composition

Received

The dental office, on open

Responded

The dentist, on answer

Date the answer was needed

The coordinator, from the clinical schedule

The clinical judgment is entirely the dentist's, and the record never characterizes it. What the record establishes is when it arrived.

Dental clearance

Examined: 09 OCT 2026
Procedure: 02 NOV 2026
Re-evaluate after

The line nobody can fill in

A clearance is a finding on a date, not a certification. Absence of acute infection at the examination does not assure that nothing arises in the weeks before the procedure, and no standard anywhere sets a re-evaluation interval. That is why the third line is blank, and why the series above found follow-up inadequate in fifteen of the twenty-nine patients who needed a second look.

Illustration, not a form. This is not a CMS or ADA instrument and no part of it is a coverage determination. Medical necessity and timing belong to the treating team.

The evidence behind this

Free, cited, and including the findings that cut against us. The evidence base for this whole field is thinner than its confidence suggests, and saying so is the point.

Coordination is the most common reason radiation starts late

In a prospective cohort, the most common primary reason a head and neck patient missed the timely radiation window was poor care coordination: nineteen of forty-six patients, 41.3%. Separately, in a national database of surgically managed head and neck cancer, starting radiation more than six weeks after surgery was associated with worse overall survival, adjusted hazard ratio 1.13 (99% confidence interval 1.08 to 1.19, n=41,291).

Nguyen M, Kistner-Griffin E, DeMass R, et al. Barriers and timely postoperative radiation therapy in head and neck cancer. JAMA Otolaryngol Head Neck Surg 2025;151(12):1186. doi:10.1001/jamaoto.2025.2824. Small prospective cohort; the 41.3% is a share of the 46 patients without timely radiation, not of all patients. Graboyes EM, Garrett-Mayer E, Ellis MA, et al. Cancer 2017;123(24):4841-4850. doi:10.1002/cncr.30939. National Cancer Data Base, 2006 to 2014, observational and adjusted: an association, not proof that delay causes the difference. Neither study measured ReferralRight.

Skipping the dentist before radiation has a measured cost

In a pilot cohort of fifty patients who could not or would not have their extractions before radiation, twenty declined extractions afterward and thirty went ahead. Within two years, 40% of those thirty developed exposed bone (95% confidence interval 22% to 58%), against 7% of those who did not have extractions (0% to 22%). Eight of the thirteen cases of exposed bone were confirmed osteoradionecrosis.

Ward M, Petersen C, Noll J, et al. Planned dental extractions after radiation therapy. JAMA Otolaryngol Head Neck Surg 2024;150(10):851. doi:10.1001/jamaoto.2024.2353. Pilot, single academic department, no formal power calculation, intervals wide. The authors conclude that extractions after radiation carry considerable risk even inside a four month window. It does not show that pre-radiation clearance is risk free, and it does not measure ReferralRight.

The measured delay

Three intervals in one series, all measured: six days from consultation to surgery, twenty-two from surgery to clearance with a range reaching one hundred nineteen, and twenty-eight from consultation to the start of radiation with a range reaching one hundred thirty-three. Twenty-nine patients needed extended healing or repeat visits, and follow-up was recorded as inadequate in fifteen of them.

Dufresne E, Schmittbuhl M, Herrero Babiloni A. Surgical extraction-related dental clearance delays before radiotherapy in head and neck cancer: a descriptive study from a Canadian tertiary center. Spec Care Dentist 2026;46(1):e70134. PMID 41482510, PMC12759029, doi:10.1111/scd.70134. Single centre, n=356 of 463 scheduled for radiotherapy, one calendar year, descriptive only. The authors state no timing benchmark exists for patients treated with radiation without prior surgery, and that the 42 day figure is a contextual benchmark for exploratory comparison rather than a formal standard. Label it that way or do not cite it.

Who actually bills Medicare for dental

In calendar year 2024, six hundred twenty-nine providers billed Medicare Part B for dental services, of whom one hundred sixty-six were general dentists. Total paid was $8.3 million, the median provider was paid $3,118, and the top one hundred providers accounted for 74.6% of all dollars. Separately, 9,411 dental NPIs are enrolled, which is 2.43% of the profession.

CMS Medicare Physician and Other Practitioners public use file, CY2024, verified 2026-08-12; enrollment counts from the CMS Public Provider Enrollment file. Enrolled and billing are different facts and we report them separately. Read 629 as a floor, not a census: that file excludes facility-billed claims and Medicare Advantage entirely, and suppresses any cell under eleven beneficiaries, so a provider with a handful of dental claims does not appear.

What the clearance evidence does and does not show

For head and neck radiation, the case for extraction before treatment is strong and the timing argument is the whole argument. For cardiac and solid organ transplant, the benefit of routine clearance is genuinely unproven: there are no randomized trials in solid organ transplant, and KDIGO grades dental evaluation 2C while stating it is not mandated.

We publish this because it is true, and because a program requiring clearance owes its patients a fast one either way.

You sent it. Then you called to find out.