Form 22 - Caries Assessment Risk

Caries Risk Management Form

Patient Identification¹

• Oral Health Centre of Western Australia
• Use Patient Barcode Label
• Given Name: ________
• Surname: ________
• DOB: ________
• TEMP: ________

Assessment Date

• Assessment date: __________; Baseline or Recall (circle)

Disease Indicators (any one ‘YES’ signifies likely ‘High Risk’ and to do a bacteria test)*

• Visible cavities or radiographic penetration of the dentine (YES)
• Radiographic approximal enamel lesions (not in dentine) (YES)
• White spots on smooth surfaces (YES)
• Restorations last 3 years (YES)

Risk Factors (Biological predisposing factors)

• MS and LB both medium or high (by culture*) (YES)
• Visible heavy plaque on teeth (YES)
• Frequent snack (>3 x daily between meals) (YES)
• Deep pits and fissures (YES)
• Recreational drug use (YES)
• Inadequate saliva flow by observation or measurement (if measured, note flow rate on opposite page) (YES)
• Saliva reducing factors (medications/radiation/systemic) (YES)
• Exposed roots (YES)
• Orthodontic appliances (YES)

Protective Factors

• Lives/work/school fluoridated community (YES)
• Fluoride toothpaste at least once daily (YES)
• Fluoride toothpaste at least 2 x daily (YES)
• Fluoride mouthrinse (0.05% NaF) daily (YES)
• 5,000 ppm F fluoride toothpaste daily (YES)
• Fluoride varnish in last 6 months (YES)
• Office F topical in last 6 months (YES)
• Chlorhexidine prescribed/used one week each of last 6 months (YES)
• Xylitol gum/lozenges 4 x daily in last 6 months (YES)
• Calcium and phosphate paste during last 6 months (YES)
• Adequate saliva flow (>1 ml/min stimulated) (YES)

Patient Identification and Clinical Assessment

Bacteria Test Results

• *Bacteria test results: MS:_____ L.B.:_____ Date:_____

Visualise Caries Balance

• (Use circled indicators/factors above)

Caries Risk Assessment (circle)

• Extreme / High / Moderate / Low

Signatures

• Clinician Signature: ________ Clinician ID: ________
• Supervisor Signature: (If student clinician) ________ Supervisor ID: ________
• Date: ________
• Do not write within this shaded area.

Saliva Testing and Plaque Assessment

Saliva Testing (item 047)²

Parameter	Resting Saliva	Stimulated Saliva
Baseline (Date)	//___	//___
Recall (Date)	//___	//___
Recall (Date)	//___	//___

Plaque Scores

• Plaque score at baseline % _____; Date //
• Plaque score at recall % _____; Date //
• Plaque score at recall % _____; Date //

Caries Disease Management

Saliva Testing Parameters

Short term

• Disease indicators:
• Risk factors:
• Protective factors:

Medium term

• Disease indicators:
• Risk factors:
• Protective factors:

Long term

• Disease indicators:
• Risk factors:
• Protective factors:

Signatures

• Clinician Signature: ________ | Clinician ID: ________ | Date: ________
• Supervisor Signature: (If student clinician) ________ | Supervisor ID: ________

Footnotes

1. Original PDF page 1: Form 22 - Caries Assessment Risk, p.1 ↩

2. Original PDF page 2: Form 22 - Caries Assessment Risk, p.2 ↩