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    Caries Risk Assessment Form 6

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    dhelianjani

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    © All Rights Reserved
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    Caries Risk Assessment Form 6

    Uploaded by

    dhelianjani
    457 views3 pages

    Copyright

    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    457 views3 pages

    Caries Risk Assessment Form 6

    Uploaded by

    dhelianjani

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Caries Risk Assessment Form (Age >6)

    Patient Name:

    Birth Date: Date:

    Age: Initials:

    Low Risk Moderate Risk High Risk

    Contributing Conditions Check or Circle the conditions that apply


    Fluoride Exposure (through drinking water, supplements,
    I. Yes No
    professional applications, toothpaste)
    Frequent or
    Primarily
    Sugary Foods or Drinks (including juice, carbonated or prolonged between
    II. at mealtimes
    non-carbonated soft drinks, energy drinks, medicinal syrups) meal exposures/day

    No carious lesions in Carious lesions in Carious lesions in


    Caries Experience of Mother, Caregiver and/or
    III. last 24 months last 7-23 months last 6 months
    other Siblings (for patients ages 6-14)

    Dental Home: established patient of record, receiving


    IV. Yes No
    regular dental care in a dental office
    General Health Conditions Check or Circle the conditions that apply
    Special Health Care Needs (developmental, physical,
    Yes (over age 14) Yes (ages 6-14)
    I. medi- cal or mental disabilities that prevent or limit No
    performance of adequate oral health care by themselves
    or caregivers)
    II. Chemo/Radiation Therapy No Yes
    III. Eating Disorders No Yes
    IV. Medications that Reduce Salivary Flow No Yes
    V. Drug/Alcohol Abuse No Yes
    Clinical Conditions Check or Circle the conditions that apply
    No new carious 1 or 2 new carious 3 or more carious
    Cavitated or Non-Cavitated (incipient)
    lesions or lesions or restorations lesions or restorations
    I. Carious Lesions or Restorations (visually or
    restorations in last in last 36 months in last 36 months
    radiographically evident)
    36 months
    II. Teeth Missing Due to Caries in past 36 months No Yes
    III. Visible Plaque No Yes
    Unusual Tooth Morphology that
    IV. No Yes
    compromises oral hygiene
    V. Interproximal Restorations - 1 or more No Yes
    VI. Exposed Root Surfaces Present No Yes
    Restorations with Overhangs and/or Open Margins;
    VII. No Yes
    Open Contacts with Food Impaction
    VIII. Dental/Orthodontic Appliances (fixed or removable) No Yes
    IX. Severe Dry Mouth (Xerostomia) No Yes

    Overall assessment of dental caries


    Low Moderate High
    risk:
    Patient Instructions:
    © American Dental Association, 2009, 2011. All rights
    reserved.
    Caries Risk Assessment Form (Age >6)

    Circle or check the boxes of the conditions that apply. Low Risk = only conditions in “Low Risk” column
    present; Moderate Risk = only conditions in “Low” and/or “Moderate Risk” columns present; High Risk =
    one or more conditions in the “High Risk” column present.

    The clinical judgment of the dentist may justify a change of the patient’s risk level (increased or decreased)
    based on review of this form and other pertinent information. For example, missing teeth may not be
    regarded as high risk for a follow up patient; or other risk factors not listed may be present.

    The assessment cannot address every aspect of a patient’s health, and should not be used as a replacement
    for the dentist’s inquiry and judgment. Additional or more focused assessment may be appropriate for patients
    with specific health concerns. As with other forms, this assessment may be only a starting point for
    evaluating the patient’s health status.

    This is a tool provided for the use of ADA members. It is based on the opinion of experts who utilized
    the most up-to-date scientific information available. The ADA plans to periodically update this tool based
    on: 1) member feedback regarding its usefulness, and; 2) advances in science. ADA member-users are
    encouraged to share their opinions regarding this tool with the Council on Dental Practice.

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