Re: ___________________________________________ DOB: ________________
To Whom It May Concern:
Reason for referral (our office to complete): ___________________________________________
Our mutual patient noted above is scheduled to undergo total joint replacement surgery. We do not require routine dental clearance for every joint-replacement patient. We are referring this patient specifically because they have a symptomatic or suspected active oral infection, and/or are at elevated risk of infection. Because bacteria from an active oral infection can seed a new joint implant, we ask you to evaluate for — and treat — any active dental infection or acute oral pathology (abscess, significant periodontal infection, symptomatic or fractured teeth) before surgery.
Timing: If invasive dental work is needed, please complete it with time to heal before the surgery date — at least 2 weeks for the mucosa, and ideally about 3 weeks for an extraction socket. We would rather move the surgery date than operate with an active or unhealed oral infection. Routine cleanings and non-urgent restorative work do not need to be completed before surgery.
_____ No active oral infection or acute pathology found. No dental treatment is needed before surgery.
_____ An active issue was identified and treatment is underway. Anticipated completion / healing date: ___________________ (so we can time surgery to allow healing).
Dentist name (please print): ___________________________________________
Dentist signature: ___________________________________________
Date: _________________________
This letter is an important part of our preoperative patient evaluation; please fax this letter back to us as soon as possible.
Thank you for your assistance,
Darin W Allred MD
Orthopedic Surgeon