Caries Risk Analysis Input Form - Patient Age 19 - 33

Prepared by         ,              Exam Date:     Last Assessment Date:     Prepared for     Name:     Date of Birth:     Internal Patient ID:     Previser Patient ID:

Patient History and Clinical Data

Permanent premolars and molars a) Sound or sealed b) Carious or early decalcification c) 1-2 interproximal restorations d) >2 interproximal restorations Root surfaces a) Not visible b) Visible and sound c) Carious d) Restored Months Patient has been Caries free a) 36 or more b) 24 - 35 c) 12 - 23 d) Less than 12 Erosion, abrasion, or abfraction on Root Surfaces A tooth has been fractured A tooth that is present has root canal fillings and is not restored with a crown Oral Hygiene Excellent: improvement not possible Acceptable: slight improvement possible Unacceptable: substantial improvement needed       Fluoride products are used (Fluoridated water, toothpaste, rinses or gels) Has fixed orthodontic appliance Experiences dry mouth Bruxes, grinds, or clenches. - OR - Symptoms of habits like occlusal or incisal wear, tooth facets, or cervical wear exist Has a pierced tongue or oral habits like eating ice, playing a musical instrument with a mouthpiece, or opening a bottle that places excessive stress on the teeth       a) 5 or More b) 4 or Less   Times per day snacks or beverages containing sugar are consumed between meals

Treatments Performed since last Risk Assessment

Preventive Treatment Prophylaxis/Maintenance # procedures   Nutritional counseling/referral # times Sealants # teeth   Tobacco counseling/referral # times Topical fluoride # procedures   Medical condition referral # times Oral hygiene instruction # times   Oral habit instruction # times Therapeutic Oral Rinse # weeks   Bite guard # procedures       Related to Teeth   Related to Tooth Replacement Restorations # teeth   Extractions # teeth Endodontics # teeth   Single tooth replacement - implants # implants Related to Periodontium   Fixed prosthesis # prostheses Systemic chemotherapy # weeks   Teeth abutments # teeth Local delivery - chemotherapy # sites   Implant abutments # implants Scaling and root planing # quadrants   Pontics # pontics Surgery-pockets, vertical bone, furcas # quadrants   Removable prosthesis # prostheses Surgery-other # procedures   Implant abutments # implants   Provisional splinting # teeth+pontics