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Caries Risk Assessment
(Teledental)
First Name
Required!
Last Name
Required!
Date of Birth
Required!
Member Number
Required!
Provider Name
Required!
Date of Evaluation
Required!
Contributing Conditions
1.
Fluoride Exposure (through drinking water, supplements, professional applications, toothpaste)
No
Yes
Required!
2.
Sugary Foods/Drinks (including juice, carbonated or non-carbonated soft drinks, energy drinks, medicinal syrups)
None/Primarily at Mealtimes
Frequent or Prolonged Exposure
Required!
3.
Caries experience of mother, caregiver, and/or other siblings (0-14 y/o)
No carious lesions in last 24 months
Carious lesions in last 7-23 months
Carious lesions in last 6 months
Required!
4.
Dental Home (receiving regular dental care in a dental office within the past 18 months)
No
Yes
Required!
5.
Brushing with toothpaste containing Fl (OTC or RX)
No or less then 1X daily
Yes (1X or non Fl)
Yes (2X daily)
Required!
General Health Conditions
1.
Special health care needs (developmental, physical, medical, or mental disabilities that prevent or limit performance of adequate oral health care by themselves or caregivers)
No
Yes (15+ y/o)
Yes (0-14 y/o)
Required!
2.
Chemo/radiation therapy
No
Yes
Required!
3.
Eating Disorders (6+ y/o)
No
Yes
Required!
4.
Medications that reduce salivary flow
No
Yes
Required!
Clinical Conditions
1.
Cavitated carious lesions or restorations (visually evident)
No new carious lesions or restorations in last 36 months
1-2 new carious lesions or restorations in last 36 months
3 or more new carious lesions or restorations in last 36 months
Required!
2.
Teeth missing due to caries in past 36 months
No
Yes
Required!
3.
Dental/orthodontic appliances (fixed or removable)
No
Yes
Required!
4.
Severe dry mouth (Xerostomia)
No
Yes
Required!
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