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dental

Caries Risk Assessment Form (Age > 6)

Check the conditions that apply

Contributing Conditions

  1. Fluoride Exposure

  2. Sugary Foods or Drinks


  3. Caries Experience of Mother, Caregiver and/or Other Siblings



  4. Dental Home

General Health Conditions

  1. Special Health Care Needs

  2. Chemo/Radiation Therapy

  3. Eating Disorders

  4. Medications that Reduce Salivary Flow

  5. Drug/Alcohol Abuse

Clinical Conditions

  1. Cavitated or Non-cavitated Lesions



  2. Teeth missing due to caries in past 36 month

  3. Visible Plaque

  4. Unusual Tooth Morphology

  5. Interproximal restoration

  6. Exposed Root Surfaces

  7. Restorations with overhangs and/or Open Margins open contracts

  8. Dental/Orthodontic appliances

  9. Severe Dry Mouth (Xerostomia)

Caries Risk Assessment Form (Age 0–6)

Check the conditions that apply

Contributing Conditions

  1. Fluoride Exposure

  2. Sugary Foods or Drinks



  3. Eligible for Government Programs

  4. Caries Experience of Mother, Caregiver and/or Other Siblings



  5. Dental Home

General Health Conditions

  1. Special Health Care Needs

Clinical Conditions

  1. Visual or Radiographically Evident Restorations/Cavitated Carious Lesions



  2. Non-cavitated (incipient) Carious Lesions


  3. Teeth Missing Due to Caries

  4. Visible Plaque

  5. Dental/Orthodontic Appliances Present

  6. Salivary Flow