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

Date

Dr. Periodontist
Address
City, State  Zip

Dear Dr. Perio:

I have referred [patient] to you for comprehensive periodontal treatment.  FMX taken 4/27/2010 enclosed.  Dr. OralSurgeon took a recent panelipse radiograph.

Jane was new to me last month.  She presented with #31 root fracture.  She was referred to Dr. OralSurgeon who extracted the tooth.

Today we did our new patient exam.

• Last dental work was about 4 years ago.
• She said she has had periodontal surgery many years ago.
• Many 5 & 6mm pockets; generalized attachment loss.
• #8-x-10 has a temporary bridge made about 5 years ago; recurrent caries; perforated.
• She had a nightguard in the past.  Dog chewed it up; she now wears an over-the-counter sports guard.
• Very heavy black tobacco stain.

My preliminary restorative treatment plan:

• #8-x-10 fixed bridge
• #15 crown (has fractured cusp)
• nightguard

You might uncover more restorative needs during her initial therapy.

I explained to her that she has very active periodontal disease, and might need aggressive treatment to avoid further tooth loss; importance of 3-month cleanings for the long term; possibility that even with treatment she will still lose some teeth.

Sincerely,

Dr. _____