Leeds Dental Institute – Endodontic Referral Form
Please refer to the guidelines overleaf before completing this form – ALL sections MUST BE FULLY
completed
PRACTICE DETAILS
Referrer Name:
Date of Referral:
Practice Address:
Tel:
Fax:
Postcode:
Type of referral:
Email:
Routine
Urgent
PATIENT DETAILS
Name:
DOB:
Sex:
Male
Female
Contact Address:
Tel (Home/Work/Mobile):
Postcode:
NHS no/Hospital no:
Please state which service you would like:
Diagnosis & Treatment planning
Please tick to confirm that treatment of primary dental
disease has been undertaken
Tooth of concern:
Treatment
BPE scores:
Please tick to confirm the inclusion of a radiograph of good diagnostic value
Please provide a brief history of the problem being referred AND synopsis of recent intervention:
For which reason(s) is the tooth of importance:
Mastication
Appearance
Occlusal stability
Strategic (e.g. abutment)
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The tooth is restorable and has good periodontal support
Please tick the
following boxes
to confirm that:
The patient understands that if accepted for treatment, they must be available to attend the LDI for several
long appointments
The patient understands you will provide the coronal restoration following treatment
Medical History:
Signed:
Date:
Endodontic Referral Guidelines
Referrals must contain:
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Fully completed endodontic referral form
A periapical radiograph of diagnostic value
Confirmation that the tooth has good periodontal and restorative status
An important reason to retain the tooth
Referrals will be returned if:
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They are illegible
The form is incomplete or does not meet the referral criteria set out by the Health Authority
Criteria for acceptance for treatment:
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For advice only on complex endodontic problems and/or a pain diagnosis
Single/multiple root canals with anatomical complexities e.g. curvatures of >40°
Single/multiple root canals that are NOT considered negotiable from radiographic or clinical evidence
through their entire length. This is on the understanding that patients will be returned to you for
completion of root canal treatment and final restoration.
For endodontic complications of trauma e.g. tooth with open apices, root fractures, etc.
Periradicular surgery of failed RCT in the presence of adequate conventional obturation
Pathological resorption
Feasible removal of fractured instruments and intra-radicular posts in teeth of reasonable prognosis
Root perforations
Conventional re-treatment of failed root canal treatment (including retrieval of gutta percha, resin and/or
metallic root fillings).
Patients will not be offered treatment if:
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They are not registered with a dentist
They have poor OH, active caries and/or active periodontal disease
The referral has been made on the patients inability / unwillingness to pay NHS charges
They are ‘keen to save’ but the prognosis of such teeth is considered poor
They require sedation or GA for routine dental treatment
The tooth is a second or third molar unless it is of strategic value to the overall treatment plan
March 2014