|At Risk||Not at Risk|
|Medical history: Any conditions, medications, or habits that cause dry mouth?|
|Dental history: Presence of active caries?|
|Dental history: Prior DMFS (decayed, missing, filled surfaces)?|
|Dental history: Diet that increases caries risk?|
|Dental history: Poor oral hygiene?|
|Dental history: Low levels of fluoride exposure?|
|Oral cavity factors: Tooth morphology and alignment prone to caries?|
|Oral cavity factors: Restorations with faulty margins?|
|Additional risk factors: Any cultural or social norms that increase caries risk?|
|Additional risk factors: Economic hardship?|
Another option for conducting a Risk Assessment Survey is to access and download the appropriate Caries Risk Assessment form from the ADA website. The ADA provides two different forms, one designed for patients 0-6 years, and the other for patients over the age of 6. These forms have been designed to aid the dental health practitioner in determining the level of risk present in each individual patient and can serve as an aid in both the initial assessment of risk, as well as tracking the implementation and progress against an intervention program.
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