Rdhm Periodontics Referral Form - Dental Health Services Victoria (Page 4 of 4) in pdf

Criteria – Periodontic Clinic

Appropriate

The Periodontal clinic provides diagnosis, prevention and treatment of simple to severe

patients

periodontal (gum) disease. Simple cases are only accepted where patients also have a

complex medical history.

Acceptance for treatment in this specialty is dependent on the clinical criteria below and a

demonstrated improvement in the patient’s plaque control.

Clinical criteria

- please tick options

localised/ generalised pocket depth of > 5 mm

applicable to this

patient

attachment loss of > 5 mm



any dramatic changes in gingival contour and texture or pocket depth



furcation involvement

excessive bleeding gums (e.g blood on pillow) and presence of attachment loss

(pockets)

multiple / isolated periodontal abscess formation

drifting or mobile permanent teeth

recession defects where there is an increase in recession or a major aesthetic problem

noted over professional review of 6 months

a family history of severe or very early periodontal disease, including aggressive

Periodontitis and patient displays attachment loss on several teeth of 5 mm or more

medically compromised patients e.g following transplant, with diabetes, and patient

displays attachment loss of more than 5 mm

AND the following mandatory criteria for all patients;

demonstrated ability to maintain oral hygiene with a plaque score < 15%

(shown in a minimum of 2 O’Leary plaque index scores)



Exclusions

Patients who present with plaque scores > 15% will be referred back to the referrer or

the the Dental Teaching clinic until the plaque scores are acceptable before specialist

intervention



Patients who cannot maintain a high standard of plaque control (P.I < 15%) will not

progress beyond initial phase therapy.

Emergency care

By submitting this referral, I on behalf of the referring clinic, acknowledge that the

referring clinic is responsible for any emergency care required while the patient is still

on the waiting list

On going care

By submitting this referral, I on behalf of the referring clinic, acknowledge that the

required by

referring clinic is responsible for:

referring clinician.

overall general care to this patient both while on the waiting list and throughout

treatment at RDHM

providing treatment including extractions, fillings and dentures on the recommendation

of the specialist.

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Revised September 2014

Rdhm Periodontics Referral Form - Dental Health Services Victoria Page 4

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