<table> <tr> <td colspan="2"><b>ORAL HEALTH CENTRE</b></td> <td>Use Patient Barcode Label</td> <td colspan="6"></td> </tr> <tr> <td colspan="2"><i>OF WESTERN AUSTRALIA</i></td> <td colspan="6"></td> <td>GIVEN Name</td> <td></td> </tr> <tr> <td colspan="2"></td> <td colspan="6"></td> <td>Surname</td> <td></td> </tr> <tr> <td colspan="2"></td> <td colspan="6"></td> <td>DOB</td> <td></td> </tr> <tr> <td colspan="2"></td> <td colspan="6"></td> <td>TEMP</td> <td></td> </tr> <tr> <td colspan="10"><b>Form</b> 22</td> </tr> <tr> <td colspan="10">Caries Risk Management</td> </tr> <tr> <td colspan="10"><b>Assessment date</b>__________; This is Base line or Recall (please circle)</td> </tr> <tr> <td colspan="9"><b>Disease indicators (any one 'YES' signifies likely 'High Risk' and to do a bacteria test*)</b></td> <td>YES = Circle</td> <td>YES = Circle</td> <td>YES = Circle</td> </tr> <tr> <td colspan="9">Visible cavities or radiographic penetration of the dentine</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Radiographic approximal enamel lesions (not in dentine)</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">White spots on smooth surfaces</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Restorations last 3 years</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9"><b>Risk factors (Biological predisposing factors)</b></td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">MS and LB both medium or high (by culture*)</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Visible heavy plaque on teeth</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Frequent snack (>3 x daily between meals)</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Deep pits and fissures</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Recreational drug use</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Inadequate saliva flow by observation or measurement ('if measured, note the flow rate on the opposit page)</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Saliva reducing factors (medications/radiation/systemic)</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Exposed roots</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Orthodontic appliances</td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9"><b>Protective factors</b></td> <td>YES</td> <td></td> <td></td> </tr> <tr> <td colspan="9">Lives/work/school fluoridated community</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="9">Fluoride toothpaste at least once daily</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="9">Fluoride toothpaste at least 2 x daily</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="9">Fluoride mouthrinse (0.05% NaF) daily</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="9">5,000 ppm F fluoride toothpaste daily</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="9">Fluoride varnish in last 6 months</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="9">Office F topical in last 6 months</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="9">Chlorhexidine prescribed/used one week each of last 6 months</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="9">Xylitol gum/lozenges 4 x daily in last 6 months</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="9">Calcium and phosphate paste during last 6 months</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="9">Adequate saliva flow (>1 ml/min stimulated)</td> <td></td> <td>YES</td> <td></td> </tr> <tr> <td colspan="10"><b>*Bacteria test results: MS:</b>_____<b>L.B.:</b>_____<b>Date:</b>_____</td> </tr> <tr> <td colspan="10"><b>Visualise Caries Balance</b></td> </tr> <tr> <td colspan="10">(Use circled indicators/factors above)</td> </tr> <tr> <td colspan="10"><b>Caries Risk Assessment (circle)</b></td> <td colspan="3">Extreme High Moderate Low</td> </tr> <tr> <td colspan="10">Clinician Signature:</td> <td></td> <td>Clinician ID:</td> <td></td> </tr> <tr> <td colspan="10">Supervisor Signature: (If student clinician)</td> <td></td> <td>Supervisor ID:</td> <td></td> </tr> <tr> <td colspan="10">Date:</td> <td colspan="3"></td> </tr> <tr> <td colspan="10">Do not write within this shaded area</td> </tr> <tr> <td colspan="11">Form 22, Version 3/2014, page 1 of 2</td> </tr> </table>  #### Patient Identification - 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) #### 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. A structured clinical assessment table titled 'Form 22 Caries Risk Management'. The table is divided into three main sections: 'Disease indicators', 'Risk factors (Biological predisposing factors)', and 'Protective factors'. Each section lists specific criteria with corresponding columns for marking 'YES' under different risk levels. The header row includes instructions to circle 'YES' if applicable. The rows contain detailed medical indicators such as 'Visible cavities or radiographic penetration of the dentine', 'MS and LB both medium or high (by culture*)', and 'Fluoride toothpaste at least once daily'. The table uses color coding (red, yellow, green) to visually distinguish between disease indicators, risk factors, and protective factors. **Form 22** **Caries Risk Management continuation** **Saliva testing (item 047)** | **Resting saliva** | | | **Stimulated saliva** | | | | :--- | :--- | :--- | :--- | :--- | :--- | | **Baseline** (Date: ___/___/___) | | | **Baseline** (Date: ___/___/___) | | | | **Recall** (Date: ___/___/___) | | | **Recall** (Date: ___/___/___) | | | | **Recall** (Date: ___/___/___) | | | **Recall** (Date: ___/___/___) | | | **Plaque score at baseline %** `________`; `Date` `___/___/___` **Plaque score at recall %** `________`; `Date` `___/___/___` **Plaque score at recall %** `________`; `Date` `___/___/___` **Caries disease management** | | **Disease indicators** | **Risk factors** | **Protective factors** | | :--- | :--- | :--- | :--- | | Short term | | | | | | | | | | | | | | | Medium term | | | | | | | | | | | | | | | Long term | | | | | | | | | **Clinician Signature:** | **Clinician ID:** | **Date:** | | :--- | :--- | :--- | | **Supervisor Signature:**<br>(If student clinician) | **Supervisor ID:** | | Form 22, Version 3/2014, page 2 of 2      #### Saliva Testing (item 047) | 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 **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: ________ Table for Saliva testing (item 047) with columns for Resting saliva and Stimulated saliva, each subdivided into Flowrate and pH. Rows are labeled Baseline and Recall (twice), with date fields provided. Visual chart for Plaque score at baseline %. It consists of two rows of ten boxes each, representing percentages from 0 to 10. The left side is labeled 8 down to 1, and the right side is labeled 1 up to 8. A line and space for Date is included. Visual chart for Plaque score at recall %. Similar to the previous one, it has two rows of ten boxes representing percentages from 0 to 10, with labels on both sides. Includes a line and space for Date. Visual chart for another Plaque score at recall %. Consistent structure with two rows of ten boxes representing percentages from 0 to 10, labeled accordingly, and includes a line and space for Date. Table for Caries disease management with columns for Disease indicators, Risk factors, and Protective factors. Rows are categorized as Short term, Medium term, and Long term, each with empty cells for data entry. [^1]: Original PDF page 1: [[Form 22 - Caries Assessment Risk.pdf#page=1|Form 22 - Caries Assessment Risk, p.1]] [^2]: Original PDF page 2: [[Form 22 - Caries Assessment Risk.pdf#page=2|Form 22 - Caries Assessment Risk, p.2]]