Children Under Age 5

• Caries Risk Indicators
• Does the mother or caregiver have a high cavity rate?
  • Yes
  • No
• Dental Considerations
• Do you see visible cavities?
  • Yes
  • No
• Have your child had a cavity in the last 12 months?
  • Yes
  • No
• How good is your oral hygiene?
  • Fair/Poor
  • Good
• Have 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
• Do you have a regular dentist that you see routinely?
  • Yes
  • No
• Medical History
• Do you have special health care needs (physical or mental handicap that impact cooperation or coordination)?
  • Yes
  • No
• Do you take medications that cause dry mouth (asthma, allergies, many others)?
  • Yes
  • No
• Have you undergone chemotherapy/radiation therapy?
  • Yes
  • No
• Dietary Habits
• What is your exposure to sweetened medicines?
  • >3 times/day
  • 1-3 times/day
  • rare
• Use of Bottle/Sippy Cup after 14 months (non-H2O)
  • Yes
  • No
• Nurses on Demand (frequent breast feeding)
  • Yes
  • No
• Dental History
• Does the water that you drink on a daily basis contain fluoride?
  • Yes
  • No
• Do you use a fluoride toothpaste?
  • Yes
  • No
• Mother/Caregiver uses 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