Peridontal Referral

Please use this form to refer a peridontal patient

 
 
 
 
 

Relevant Clinical Information
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


EXPLANATORY NOTES

#1
BPE Code
0    No bleeding or pocketing detected
1    Bleeding on probing - no pocketing > 3.5mm
2    Plaque retentive factors present - no pocketing > 3.5mm
3    Pockets > 3.5mm but <5.5mm in depth
4    Pockets > 5.5 mm in depth

Code *           Attachment loss >7mm (including recession sites) or with presence of furcation involvement.

#2
Please mark relevant box if referral is for specialist periodontal treatment.  Any sextant scores of 4 indicate need for patient assessment for specialist periodontal care (British Society of Periodontology guidelines). 

#3
Please highlight areas of particular importance including tooth mobility, furcation involvement, recession and presence/position of implants

#4
Please indicate any relevant radiographic examinations carried out in previous six months

#6
A full-mouth pocket chart will be carried out in all cases recording a BPE score of >3 in any sextant

#6
Indicate clearly if the use of LA is indicated to complete effective treatment

#7
Patients will be returned to your care on completion of initial therapy unless a specific recall interval is clearly stated (3/12 or 6/12).  A 3/12 review appointment will be routine after treatment involving full-mouth disinfection to assess progress.