Caries Risk Assessment Form
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2CARIES RISK ASSESSMENT FORM
Patient Name: __________________________________
Chart #: ______________________
Date of initial assessment: ____________
Completed by:___________________________ Reviewed by: __________________________ Date of next Recall: __________________
DISEASE INDICATORS
YES =
RISK FACTORS
YES =
PROTECTIVE FACTORS
YES =
(Any one “YES” = High Risk)
CIRCLE
(In the absence of indicators,
CIRCLE
CIRCLE
risk determined by dentist)
Visible cavities and/or lesions, or
Visible plaque on teeth
YES
Fluoridated water intake
YES
radiographic penetration into dentin
YES
Active proximal enamel lesions on xray
YES
Deep pits and fissures
YES
Fluoride toothpaste 1x daily
YES
Active white spots on smooth surfaces
YES
YES
YES
Saliva reducing factors/meds
Fluoride toothpaste 2x daily
Patient reports “dry mouth”
Restorations (for caries) in last 3 years
YES
YES
OTC fluoride rinse daily
YES
Extractions (due to caries), last 3 years
YES
Restorations with overhangs, open
YES
Rx fluoride toothpaste daily
YES
margins, or open contacts
YES
YES
Exposed roots
Fluoride varnish in last 6 mo
Ortho appliances, partials dentures
YES
Chlorhexidine I week/mo
YES
Infrequent or irregular dental care
YES
MI Paste in last 6 mo
YES
YES
Frequent snacks (>3x/day)
RISK LEVEL (Circle)
High sugar intake or >6 exposures
YES
HIGH
MEDIUM
LOW
Recreational drug use
YES
Directions:
After clinical and radiographic examination (and review of restorative history in the patient’s record), circle “YES” for all items that apply in the left column
1.
(“Disease Indicators”). Any “yes” response places the patient at High Risk.
Using information from the examination, and from interviewing the patient, circle “YES” for all items that apply in the center column (“Risk Factors”).
2.
In the absence of any Disease Indicators in the first column, the dentist determines the patient’s risk based on risk factors present.
Patients with NO circled “YES” items in the first two columns are at Low Risk. CIRCLE THE RISK LEVEL in the box above.
3.
Ask patients about each item in the right column, and circle each “YES” that applies.
Notes:
1. Students will NOT be allowed to develop a treatment plan until this form has been completed, reviewed with the supervising faculty and recommendations
based on caries risk have been given to the patient.
2. In conjunction with a comprehensive oral exam, completion of this form should take no more than 10 minutes.
3. Presence of Disease Indicators (Left Column) is the most accurate predictor of future lesion formation.
Risk Factors (Center Column) help predict future lesion formation in patients without new or recent (past 3 years) lesions, and they help identify causal agents
in patients with new or recent lesions so appropriate protective factors can be prescribed for that patient.
Protective Factors (Right Column) give an idea of the patient’s current level of protection against future lesions. (See “Recommendations Based On Caries
Risk”, on reverse side of this form.)
4. The clinical judgment of the clinical instructor may justify a change for the patient’s risk level (increased or decreased) based on review of this form and other
pertinent information.
SEE REVERSE FOR RECOMMENDATIONS
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