Fillable Printable Caries Risk Assessment Checklist

Caries Risk Assessment Checklist

ADAAmericanDentalAssociation®



Dental PBRN Study 10: Caries Risk Assessment Form (Ages >18)

Low Risk

(0)

Moderate Risk

(1)

High Risk

(10)

Patient

Risk

Contributing Conditions

Fluoride Exposure

(through drinking water, supplements, professional

applications, toothpaste)

Yes No

II.

Sugary or Starchy Foods or Drinks

(including juice, carbonated or

non-carbonated soft drinks, energy drinks, medicinal syrups)

Primarily at

mealtimes

Frequent or

prolonger

between meal

exposures/day

III.

Dental Home: established patient of record, receiving regular

dental care i n a dental office

Yes No

General Health Conditions

I. Special Health Care Needs* No

Yes

(over age 14)

Yes

(ages 6-14)

II. Chemo/Radiation Therapy No Yes

III. Eating Disorders No Yes

IV. Smokeless Tobacco Use No Yes

V. Medications that Reduce Salivary Flow No Yes

VI. Drug/Alcohol Abuse No Yes

Clinical Conditions

Cavitated or Non-Cavitated (incipient) Carious Lesions or

Restoration (visually or radio gra phically evident)

No new carious

lesions or

restorations in

last 36 months

1 or 2 new carious

lesions or

restorations in last

36 months

3 or more carious

lesions or

restorations in

last 36 months

II. Teeth Missing Due to Caries in the past 36 Months No Yes

III. Visible Plaque No Yes

IV. Unusual Tooth Morphology that compromises oral hygiene No Yes

V. Interproximal Restorations – 1 or more No Yes

VI. Exposed Root Surfaces Present No Yes

VII.

Restorations with Overhangs and/or Open Margins; Open

Contacts with Food Impactions

No Yes

VIII. Dental/Orthodontic Appliances (fixed or removed) No Yes

IX. Severe Dry Mouth (Xerostomia) No Yes

TOTAL:

Indicate0,1or10inthelastcolumnforeachriskfactor.Iftheriskfactorwasnotdeterminedorisnotapplicable,enter a0in

thepatientriskfactorcolumn.Totalthefactorvaluesandrecordthescoreatthebottomofthepage.

Ascoreof0

indicatesapatienthasalowriskforthedevelopmentofcaries.Asinglehigh riskfactor,orscoreof10,placesthe

patientathighriskfordevelopmen tofcaries.Scoresbetween1and10placethepatientatamoderateriskforthe

developmentofcaries.Subsequentscores

shoulddecreasewithreductionofrisksandtherapeuticintervention.