Self Exam

Answer all of the questions below for your personalized Dental Score report.

There are three main oral (teeth and gum) diseases: tooth decay, gum disease and oral cancer. Below we will ask you some questions that will help us estimate your risk of experiencing these diseases and their effects. Additionally, we ask if there is any disease you are currently experiencing. Please answer all of the questions below. For accurate results, answer all questions in the Self Exam to the best of your ability.

Questions that will help us assess the health of your teeth:
How old are you?
Are all of the child's teeth gone?
How many teeth has the child had extracted because of decay or abscess?
How many fillings and caps has the mother or caregiver had in the last two years?
Are Xylitol gum or lozenges used by the mother or caregiver 2-4 times per day?
Is the parent eligible for government programs (WIC, Head Start, Medicaid, SCHIP)?
What is the child's dental care frequency?
Does the child have any developmental challenges?
How many fillings has the child had in the last 2 years?
Does the child have snacks between meals?
Does the child drink fluoridated water or use fluoride toothpaste or supplements?
Does the child sleep with or continually use a bottle that is filled with a fluid other than water?
Does the child nurse on demand?
Does the child have pain when drinking cold or sweet drinks?
Has the child stopped eating foods that require chewing?
How many filled teeth does the child have?
Does the child complain that his or her mouth is dry?
Are all of your adult upper teeth gone?
Are all of your adult lower teeth gone?
How many false teeth do you have?
Do you have missing teeth that you think should be replaced but have not been replaced yet?
Do your teeth hurt when you drink hot, cold, or sweet beverages?
Do your teeth hurt when you chew?
How many adult teeth have you had extracted because of decay, looseness, or pain? (not counting wisdom or impacted teeth, or teeth knocked out by an accident or removed for orthodontics)
How many adult teeth have you had filled?
How many adult teeth have you had capped?
How many fillings and caps have you had in the last 2 years?
Do you have snacks between meals?
Have you had a major health change (like a heart attack, stroke, etc) during the past 12 months?
Questions that will help us assess the health of your gum tissue:
Do your gums bleed when you brush your teeth?
Have any teeth become loose NOT due to an accident?
Have you been told by a dental professional that you have bone loss around your teeth?
I had or am currently scheduled for a deep cleaning (scaling & root planning).
I had or am currently scheduled for gum surgery (periodontal surgery).
The frequency that I use dental floss or another device to clean between my teeth is:
The number of periodontal maintenance appointments I had in the last 24 months was:
Do you have a parent or sibling who has or had gum disease?
What is your diabetic status?
Questions that will help us determine your risk of oral cancer:
Have you had oral cancer?
Do you smoke cigarettes?
Do you use chewing or smokeless tobacco?
Do you smoke cigars or pipes?
Do you think you may have been infected with HPV (human papilloma virus)?
How many alcoholic drinks do you typically have in one week?
CONGRATULATIONS! The Self Exam is complete. Click Finish to get your report.