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September 9, 2010 Dear Consultant, Knowing the difficulty in diagnosing and treating periodontal conditions today, I assume that for you to confirm a diagnosis or confirm treatment without clinical information must be very difficult. Since periodontal diagnosis is practically impossible from x-rays, the following information is intended to aid you by describing what we saw clinically. |
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PATIENT NAME: |
Abbott, Patricia |
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EXAM DATE: |
09/09/2010 |
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DIAGNOSIS: |
Periodontitis |
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AAP DIAGNOSTIC CODE: |
123456 |
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PATIENT STATUS: |
Adult |
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GINGIVA: |
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Color: |
Pink |
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Texture: |
Glossy |
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Margins: |
Clefts |
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Attachment: |
Recession |
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Papillae: |
Blunted |
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Sulcus: |
Blood |
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Contour: |
Irregular |
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Bleeding: |
Mild |
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Suppuration: |
Mild |
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X-RAY: |
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Bone Loss: |
Moderate |
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Bone Defects: |
Craters |
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ORAL HYGIENE: |
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Plaque: |
Light |
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Calculus: |
Light |
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Stain: |
Light |
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Attached you will find my chart of the probing depths. I hope this helps speed the consultation process and the approved payment. Sincerely, Dennis D. Smith, D.D.S. |
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