Referral Criteria for Hygienists and General Dentists

Periodontitis

Refer when any of these is present:

• Probing depths of 5 mm or more with bleeding that persist after scaling and root planing and re-evaluation.
• Stage III or IV periodontitis at diagnosis (interproximal bone loss to the middle third or beyond, or tooth loss due to periodontitis).
• Furcation involvement Class II or III, or mobility Grade 2 or more.
• Grade C (rapid progression) at any stage, or a patient under 35 with bone loss.
• Vertical bony defects that may be candidates for regeneration.
• Uncontrolled disease in a patient with diabetes, cardiovascular disease, or planned joint replacement.
• A hopeless tooth where socket preservation and implant planning should happen at the time of extraction.

Staging and grading here follow the 2017 World Workshop framework of Tonetti, Greenwell and Kornman, summarized in the American Academy of Periodontology’s chairside guide: Stage III and IV are set at interdental clinical attachment loss of 5 mm or more with radiographic bone loss extending to the middle third of the root and beyond, separated by tooth loss (up to four teeth for Stage III, five or more for Stage IV), and Grade C at 2 mm or more of bone loss over five years or a bone-loss-to-age ratio above 1.0.

Gum Recession

Refer when:

• Recession of 2 mm or more that has progressed between visits, or any recession the patient can see or feel.
• Keratinized tissue under 2 mm or a thin, translucent phenotype, especially before orthodontic movement or around a planned restoration margin.
• Root sensitivity or a non-carious cervical lesion at a recession site.
• A frenum pull or shallow vestibule at a recession site.
• Thin or receding tissue around an implant, or the gray of an implant showing through.

Crown Lengthening

• A restorative margin that will sit within 2 to 3 mm of the crestal bone on the periapical, or a ferrule under 1.5 to 2 mm.
• Subgingival caries or fracture where the margin cannot be placed on sound tooth without violating the supracrestal tissue attachment.
• An esthetic case: excessive gingival display with short clinical crowns and normal tooth length on the radiograph.

The 2017 World Workshop consensus report of workgroup 3 retired the term biologic width in favour of supracrestal tissue attachment, and confirmed that restorative margins placed within the supracrestal connective tissue are associated with inflammation and loss of periodontal supporting tissue.

Implant Sites

• A tooth that is hopeless or planned for extraction: refer before the extraction so we can graft the socket or place immediately where the site allows.
• An edentulous site with visible ridge loss, a thin buccal plate, or a pneumatized sinus on the panoramic film.
• When you would like a cone-beam CT read before committing the patient to a plan; we take it here.

Peri-Implant Disease

Refer at the first sign, not the second. The 2017 World Workshop consensus report on peri-implant diseases defines peri-implantitis as bleeding or suppuration on gentle probing, plus increased probing depth compared with previous examinations, plus bone loss beyond the crestal change of initial remodeling. Where no previous records exist, that report and the case definitions paper by Renvert and colleagues allow the diagnosis on the combination of bleeding or suppuration on gentle probing, probing depths of 6 mm or more, and bone levels 3 mm or more apical to the most coronal portion of the intraosseous part of the implant. All three are needed together, and the 3 mm is measured from the implant itself, not from a baseline film. Peri-implant mucositis is bleeding on gentle probing with no bone loss beyond initial remodeling.

• Bleeding on gentle probing around an implant plus any radiographic bone change compared with the baseline film.
• Probing depths increasing over time, suppuration, or mobility of the implant or the crown.
• Cement remnants or a crown contour that traps plaque, if you would like us to manage it.

A Hopeless Tooth

Class III mobility, a grade III furcation with recurrent abscess, or less than 25 percent remaining bone support. We will confirm, and if the tooth can be kept we will say so.

What to Send

The referral slip with tooth numbers, current radiographs (full mouth or the relevant periapicals and a bitewing), your periodontal charting if you have it, and the restorative plan for implant cases. How to refer.

What Comes Back

A written consult report with diagnosis and staging, the plan and sequence, radiographs, and the maintenance interval; a treatment report after each surgical visit; and, for implants, the fixture details your lab needs. Your patient returns to you for restorative care and alternating maintenance.

Thresholds follow the 2017 World Workshop classification and current AAP guidance. They are referral triggers, not treatment rules; call if a case doesn't fit.