Older Children and Adolescents

• Disease Factors
• Do you see visible cavities?
  • Yes
  • No/Don't know
• Have you had a cavity in the last 12 months?
  • Yes
  • No
• Do you see visible plaque (yellow/white sticky substance?
  • Yes
  • No/Don't know
• Risk Factors
• Do you have deep grooves on your molars that attract food?
  • Yes
  • No/Don't know
• Have your child been diagnosed with GERD (reflux)?
  • Yes
  • No
• How good is your oral Hygiene?
  • Fair/Poor
  • Good
• Has your child been diagnosed with gingivitis?
  • Yes
  • No
• Does saliva pool in the floor of your mouth if you do not swallow for 1 minute?
  • Yes
  • No
• Are you wearing dental retainers or braces?
  • Yes
  • No
• Do you have a regular dentist that you see routinely?
  • Yes
  • No
• Do you take medications that cause dry mouth (asthma, allergies, many others)?
  • Yes
  • No
• Do you have special health care needs (physical or mental handicap that impact cooperation or coordination)?
  • Yes
  • No
• Have you undergone chemotherapy/radiation therapy?
  • Yes
  • No
• Do you drink soda or sugared drinks regularly?
  • Yes
  • No
• What is your exposure to sweetened medicines?
  • > 3 times/day
  • 1-3 times/day
  • rare
• Family history of cavities (parents or siblings)?
  • Yes
  • No
• Protective Factors
• Does the water that you drink on a daily basis contain fluoride?
  • Yes
  • No
• Do you use a fluoride toothpaste?
  • Yes
  • No
• Do you use xylitol gum/mints?
  • Yes
  • No
• Supplemental professional laboratory tests performed with the cavity free program(optional)
• Cariscreen
  • 3500-9999
  • 1500-3500
  • 0-1500
• Cariculture (bacterial culture)
  • High
  • Medium
  • Low
• Salivary Buffering Capacity
  • Low
  • Medium
  • High