Patient Information Form

TOOTH DECAY RISK ASSESSMENT:

Did you know that:

U.S. adults lose 164+ million hours of work and children lose 51+ million hours of school each year due to dental disease
Caries (dental decay) is the most prevalent disease affecting children in the U.S, and it is 100% preventable
400+ commonly used medications can cause decreased saliva flow, which greatly increases your risk of caries
Approximately 25% of dental decay is untreated among every age group (2-100)

Are you at high risk for Tooth Decay? Yes=2 points, Occasionally=1 point, No=0 points

Full Name

First NameLast Name

Phone Number

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1. Do you drink liquids other than water more than two times daily between meals?

2. Do you feel like you have a dry mouth at any time of the day or night?

3. Do you take medications daily?

4. Do you have visible white or brown spots on your teeth?

5. Do you have any root surface exposure (gum recession)

6. Do you notice plaque build-up on your teeth between brushings?

7. Do you avoid flossing your teeth daily ?

8. Do you see exposed roots at the gum line?

9. Do your wear any oral appliances?

10. Do you smoke?

11. Do you have a history of radiation therapy or Sjogren's Syndrome?

12. Do you have heart burn (esophageal reflux or GERD)?

Score total points:

0-3 Unlikely for active disease: learn more about prevention

4-6 low suspicion of active disease inflammation: seek consultation

7-10 moderate suspsicion of active disease: seek consultation

12+ high suspicion of active disease: get immediate attention