Caries Risk Assessment for a Dental Office

gradient accent Cavity Free at Three Caries Risk Assessment For a Dental Office

Cavity Free at Three Caries Risk Assessment For a Dental Office (description required)

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How to Use This Form

Risk Factors – Children 0-6 Years

Mother/caregiver of child has had active decay in the past 12 months
Child sleeps with a bottle containing juice, formula, or anything other than water
Frequent use (between meals) of bottle/non-spill cup containing beverages other than plain water (nothing added)
Frequent snacking (greater than 3x day/total) candy, carbohydrates, soda, sugared beverages, fruit juice
Child takes saliva-reducing meds (asthma, seizure, hyperactivity), hx of anemia/iron therapy, or daily liquid medications

Risk Factors – Oral Exam/Clinical Findings

Obvious decay present on the child’s teeth
Dental fillings present
Dental plaque present
White spots present
Inadequate salivary flow
Teeth missing due to caries

Protective Factors

Child lives in a fluoridated community and drinks tap water
Teeth cleaned with fluoridated toothpaste twice daily
Child has a dental home (i.e. establish patient of record in a dental office)

Patient-Driven Self Management Goals

Patient-Driven Self Management Goals

Plan/Assessment

Clinical caries risk? (At least one risk factor indicated, regardless of protective factors)

Engaging in a Conversation With Your Patient Around Oral Health

Fluoride

Billing Guidance

Resources

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