Recall Caries Risk Assessment Form

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Recall Caries Risk Assessment Form
Date: ____________________
Disease Factors
1
New Visible cavitations
yes
no
Cavity in the last three
years
yes
no
Radiographic lesions
yes
no
2
Protective Factors
White spot lesions
yes
no
Fluoridated water
yes
no
Fluoridated toothpaste
yes
no
Adequate saliva flow
yes
no
Fluoride mouth rinse
yes
no
Xylitol gum/mints
yes
no
CariFree rinse
yes
no
Other prescription rinse
yes
no
Date: ____________________
no
Disease Factors
CARIES RISK ASSESSMENT
HIGH
1
New Visible cavitations
yes
no
Cavity in the last three
MODERATE
LOW
years
yes
no
Radiographic lesions
yes
no
Protective Factors
2
White spot lesions
yes
no
Fluoridated water
yes
no
Fluoridated toothpaste
yes
no
Adequate saliva flow
yes
no
Fluoride mouth rinse
yes
no
Xylitol gum/mints
yes
no
CariFree rinse
yes
no
Other prescription rinse
yes
no
Date: ____________________
no
Disease Factors
CARIES RISK ASSESSMENT
HIGH
1
New Visible cavitations
yes
no
Cavity in the last three
MODERATE
LOW
years
yes
no
Radiographic lesions
yes
no
2
Protective Factors
White spot lesions
yes
no
Fluoridated water
yes
no
Fluoridated toothpaste
yes
no
Adequate saliva flow
yes
no
Fluoride mouth rinse
yes
no
Xylitol gum/mints
yes
no
CariFree rinse
yes
no
Other prescription rinse
yes
no
Date: ____________________
no
Disease Factors
CARIES RISK ASSESSMENT
HIGH
1
New Visible cavitations
yes
no
Cavity in the last three
MODERATE
LOW
years
yes
no
Radiographic lesions
yes
no
Protective Factors
2
White spot lesions
yes
no
Fluoridated water
yes
no
Fluoridated toothpaste
yes
no
Adequate saliva flow
yes
no
Fluoride mouth rinse
yes
no
Xylitol gum/mints
yes
no
CariFree rinse
yes
no
Other prescription rinse
yes
no
Date: ____________________
no
Disease Factors
CARIES RISK ASSESSMENT
HIGH
1
New Visible cavitations
yes
no
Cavity in the last three
MODERATE
LOW
years
yes
no
Radiographic lesions
yes
no
2
Protective Factors
White spot lesions
yes
no
Fluoridated water
yes
no
Fluoridated toothpaste
yes
no
Adequate saliva flow
yes
no
Fluoride mouth rinse
yes
no
Xylitol gum/mints
yes
no
CariFree rinse
yes
no
Other prescription rinse
yes
no
no
CARIES RISK ASSESSMENT
HIGH

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