CARIES RISK FACTORS & ACTIVITY ASSESSMENT
 
 
RISK FACTOR
INDEX
[ At Risk
Weight of Items
Active Carious Lesions **If present - complete activity assessment 1 or more
5
DMFT Score  8 or more  
1
Most Recent Restoration Less than one year ago  
2
Root Surface Susceptibility Any exposed root surfaces  
1
Newly Erupted Teeth Any teeth erupted within past 2 years  
1
Systemic Fluoride Exposure Lack of fluoridated water or fluoride supplement  
1
Topical Fluoride Exposure Lack of ADA accepted dentifrice/oral rinse  
2
Diet
(Fermentable Carbohydrate)		 6 or more consumptions/day  
2
Other Factors*** (Identify)
1
RISK SCORE = 
RISK ASSESSMENT:

RISK SCORE RISK

1 - 2 Low

3 – 4 Moderate

 5 or more High

** Patients with active carious lesions are considered HIGH RISK for at least one Recall Cycle
*** Other Risk Factors: Any condition(s) the examiner determines may contribute to an increased risk for caries. These may include, but are not limited to:  Occlusal Anatomy Systemic Disease 

Enamel Surface Characteristics Decreased Salivary Flow

Tooth Position/Alignment Medications known to cause Xerostomia

Oral Hygiene Manual Dexterity
ACTIVITY ASSESSMENT:  Moderate: 1-2 active lesions

High: 3 or more active lesions or (special circumstances)
** If patient does not have active lesions, use RISK ASSESSMENT FORM to determine their current CARIES RISK

CARIES ACTIVITY TREATMENT PROTOCOLS

Directions: This form should be documented in the CRT and filed as a permanent part of the patient’s record.

Check off the preventive measures that are recommended and/or prescribed for the patient.

MODERATE CARIES ACTIVITY (1-2 LESIONS)

HIGH CARIES ACTIVITY (3 OR MORE LESIONS) * If patient has > 8 lesions, refer to graduate clinic or AEGD for temporaries

Procedure Codes:

04250 Caries susceptibility

04150 Bacteriologic studies

12400 Fluoride Rx

09990 Miscellaneous procedures by report

Date: ____________________________

Student: ____________________________
 
 

Faculty: ____________________________