REFERRAL FORM
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25 E. Washington St. Suite 2033 | Chicago, IL 60602
(312) 782-4068
WHO IS A QUALIFIED PERIODONTAL REFERRAL?
Patients that have the following conditions:
- Severe chronic periodontitis
- Moderate to severe acute or chronic periodontitis
- Furcation involvement
- Vertical/angular bony defect(s)
- Aggressive periodontitis (formerly known as juvenile, early-onset, or rapidly progressive periodontitis)\
- Periodontal abscess and other acute periodontal conditions
- Significant root surface exposure and/or progressive gingival recession
- Peri-implant disease
- Any patient with periodontal diseases, regardless of severity, who the referring dentist prefers not to treat
- Any patient that needs an extraction, bone graft, sinus bone graft, implants services, or help with one of these conditions.
PATIENTS THAT MAY BENEFIT FROM A REFERRING DENTIST OR PERIODONTIST
Any patient with periodontal inflammation/infection and the following systemic conditions:
- Diabetes
- Pregnancy
- Cardiovascular disease
- Chronic respiratory disease
Any patient who is a candidate for the following therapies who might be exposed to risk from periodontal infection, including but not limited to the following treatments:
- Cancer therapy
- Cardiovascular surgery
- Joint-replacement surgery
- Organ transplantation
PATIENTS WITH PERIODONTAL DISEASE THAT ARE LIKELY TO BENEFIT FROM A SECOND OPINION
Any patient with periodontitis who demonstrates at reevaluation or any dental examination any of the following risk factors/indicators known to contribute to the progression of periodontal diseases:
- Early onset of periodontal diseases (prior to the age of 35)
- Unresolved inflammation at any site (e.g., bleeding upon probing, pus, and/or redness)
- Pocket depths >5 mm
- Vertical bone defects
- Radiographic evidence of progressive bone loss
- Progressive tooth mobility
- Progressive gum attachment loss
- Anatomic gum deformities
- Exposed root surfaces
- A deteriorating risk profile