Caries Risk Assessment Checklist

ADAAmericanDentalAssociation®
Dental PBRN Study 10: Caries Risk Assessment Form (Ages >18)
Low Risk
(0)
Moderate Risk
(1)
High Risk
(10)
Patient
Risk
Contributing Conditions
I.
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
I.
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:
Indicate0,1or10inthelastcolumnforeachriskfactor.Iftheriskfactorwasnotdeterminedorisnotapplicable,enter a0in
thepatientriskfactorcolumn.Totalthefactorvaluesandrecordthescoreatthebottomofthepage.
Ascoreof0
indicatesapatienthasalowriskforthedevelopmentofcaries.Asinglehigh riskfactor,orscoreof10,placesthe
patientathighriskfordevelopmen tofcaries.Scoresbetween1and10placethepatientatamoderateriskforthe
developmentofcaries.Subsequentscores
shoulddecreasewithreductionofrisksandtherapeuticintervention.
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