Contributing Conditions

1. Fluoride Exposure

   yes no

2. Sugary Foods or Drinks

   Primarily at meals
   Frequent or prolonged between meal exposures/day

3. Caries Experience of Mother, Caregiver and/or Other Siblings

   No carious lesions in last 12 months
   Carious lesions in last 7–23 months
   Carious lesions in last 6 months

4. Dental Home

   yes no

General Health Conditions

1. Special Health Care Needs

   no yes (over age 14) yes ( age 6-14)

2. Chemo/Radiation Therapy

   no yes

3. Eating Disorders

   no yes

4. Medications that Reduce Salivary Flow

   no yes

5. Drug/Alcohol Abuse

   no yes

Clinical Conditions

1. Cavitated or Non-cavitated Lesions

   No new carious lesions or restorations in past 36 months
   1 or 2 new Carious lesions or restorations in last 36 months
   3 or more carious lesions or restorations in last 36 months

2. Teeth missing due to caries in past 36 month

   no yes

3. Visible Plaque

   no yes

4. Unusual Tooth Morphology

   no yes

5. Interproximal restoration

   no yes

6. Exposed Root Surfaces

   no yes

7. Restorations with overhangs and/or Open Margins open contracts

   no yes

8. Dental/Orthodontic appliances

   no yes

9. Severe Dry Mouth (Xerostomia)

   no yes