Wiseman Caries Risk Assessment Sample Form
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1Caries Risk Assessment Form
Patient Name: ________________________________________________________________
Date: _____________
Factors increasing risk for future cavities may include, but are not limited to:
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Moderate Risk Factors
High Risk Factors
3 or more carious lesions/restorations
Active caries in previous 12 months
Drug/alcohol abuse
in last 36 months
Poor oral hygiene
Numerous multi-surface restorations
Teeth missing due to caries in last
High titers of cariogenic bacteria
36 months
Eating disorders
Active orthodontic treatment
Cariogenic diet (frequent high sugar
Presence of exposed root surfaces
and acidic food/drinks)
(fixed or removable)
Restoration overhangs and open margins
Xerostomia (medication, radiation,
Poor family dental health
disease induced)
Prolonged nursing (bottle or breast)
Genetic abnormality of teeth
Chemo/radiation therapy
Developmental or acquired enamel defects
Suboptimal fluoride exposure
Physical or mental disability which
prevents proper oral health care
Irregular professional dental care
Other ___________________
Diagnosis
Low Risk = no factors checked
Moderate Risk = only moderate risk factors checked
High Risk = at least one condition in high risk checked
Proposed treatment for improved prognosis:
The American Dental Association recommends the use of in-office fluoride varnish or a 4 minute (APF) gel every 3–6 months and home use
prescription strength fluoride toothpaste or rinse for patients who are at an elevated risk for caries.
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This form is adapted from the American Dental Association Publications —
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3M ESPE Dental
Caries Risk Assessment Form (Age > 6)
2510 Conway Avenue
St. Paul, MN 55144-1000
Weyant RJ, Tracy SL, Anselmo T, Beltran-Aguilar ED, et al. Topical Fluoride for Caries Prevention: Executive Summary
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USA
of the Updated Clinical Recommendations and Supporting Systematic Review. JADA 2013;144(11):1279-1291.
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