Dr. Name
Office address
City, State ZIP
(or preferably print on letterhead)

DATE

Dr. Periodontist
Address
City, State  Zip

Dear Dr.Periodontist:

I have referred [patient name] to you for restorative/implant/perio consultation.  Perio charting and full mouth x-rays from 9/3/2011 enclosed (you may keep).

Today we completed a scale & prophy, exam, radiographs.

Problems noted:

• Generalized recession, especially 20 & 21
• Many areas of lack of attached gingiva
• Missing 19 (extracted over 30 years ago)
• Supraerupting 14; tipped 18
• Possible pin perforating root on 4 distal; old restoration encroaching biologic width
• Large failing restorations and/or fractures on 2, 3, 4, 13, 14, 18, 29, 30, 31
• Caries 2, 3, 12
• Abfraction 20 & 21 buccals
• Generalized occlusal/incisal attrition
• Generalized mobility

Preliminary treatment plan:

• Crowns #2, 3, 4, 13, 14 (to correct supraeruption), 18, 29, 30, 31.
  (2 & 3 are first priority because of caries)
• 12 Occlusal composite; 20 & 21 buccal composites
• 19 Implant-retained crown
• Nightguard

Possible specialist treatment:  gingival grafting; #19 implant; upright #18; crown lengthening #4.

I would like to meet with you in person and discuss her treatment plan after you evaluate her.

Sincerely,

Dr. _______