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.
Chapter 02
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 sample 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.
Chapter 03
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 the pickup code from the fax cover sheet.
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 patients, physicians and dentists. Nobody needs an
account to send or answer a referral.
Chapter 04
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
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.
Chapter 05
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.
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 other treatments
the benefit of routine clearance is genuinely unproven: the randomized trials
do not exist, and the guideline that addresses dental evaluation grades it
low-certainty 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.
Chapter 06
Questions coordinators ask
How do I get a patient's dental clearance back before cancer treatment starts, on time?
Put the date the answer is needed on the referral and have the dentist answer on the same record. With ReferralRight the dentist gets a secure link, answers in a browser, and the answer lands on the case with the time it arrived.
Who tracks whether the dentist sent the clearance back?
The record does. Every ReferralRight case carries four dates: referred, received, responded, and the date the answer was needed, so the referring team and the dental office both see who is waiting on whom without a phone call.
Does the dentist need an account or software to answer a clearance referral?
No. The dentist opens a link and confirms the patient's date of birth in a browser, or enters the pickup code from the fax cover sheet. There is nothing to install and no account to make.
Does ReferralRight need an Epic integration?
No. The loop runs without any integration and without anything to install. A hospital that later wants it inside Epic can build the interface.
What lands in the chart when the dentist answers?
One page signed by the dentist, with the dates referred, received and responded and the date the answer was needed. The clinical judgment is the dentist's; the record establishes when it arrived.
Is a community dentist slower than a hospital dental clinic?
We have no verified figure that says a community dentist is slower. One retrospective comparison of three screening programs (J Am Dent Assoc 2025, doi:10.1016/j.adaj.2025.07.009) found no statistically significant difference in time to clearance between in-house and community dentists. We do not quote its day figures here.
What does ReferralRight cost?
ReferralRight is free for patients, physicians and dentists, and nobody needs an account to send or answer a referral.