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Oral Health Assessment Form For Adults, 2013
Oral Health Assessment Form For Adults, 2013
Annex 3
Leave blank Year Month Day Identification No. Orig/Dupl Examiner
(1) (4) (5) (10) (11) (14) (15) (16) (17)
Ethnic group (27) (28) Other group (29) (30) Years in school (31) (32) Occupation (33)
Community (geographical location) (34) (35) Location Urban (1) Periurban (2) Rural (3) (36)
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Permanent teeth
Occ (45–54)
Status
Mes (55–70)
0 = Healthy
Buc (71–86) 1 = Caries
2 = Filled w/caries
Dis (87–102) 3 = Filled no/caries
4 = Missing due to
Oral (103–118) caries
5 = Missing for
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 another reason
6 = Fissure sealant
Occ (119–128) 7 = Fixed partial
denture,/crown,
abutment, veneer,
Mes (129–144)
implant
8 = Unerupted
Buc (145–160)
9 = Not recorded
Dis (161–176)
Oral (177–192)
Score
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 0 = Absence of condition
1 = Presence of condition
Bleeding (193) (208) 9 = Tooth excluded
X = Tooth not present
Pocket (209) (224)
Pocket
Bleeding (225) (240)
Score
0 = Absence of condition
Pocket (241) (256)
1 = Pocket 4–5 mm
2 = Pocket 6 mm or more
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 9 = Tooth excluded
X = Tooth not present
World Health Organization
Oral Health Assessment Form for Adults, 2013
Denture(s)
Oral mucosal lesions
(270) (273)
Upper Lower
(271) (274)
(276) (277)
(272) (275)
Condition Location
Status
0 = No abnormal condition 0 = Vermillion border
1 = Malignant tumour (oral cancer) 1 = Commissures 0 = No denture
2 = Leukoplakia 2 = Lips 1 = Partial denture
3 = Lichen planus 3 = Sulci 2 = Complete denture
4 = Ulceration (aphthous, herpetic, traumatic) 4 = Buccal mucosa 9 = Not recorded
5 = Acute necrotizing ulcerative gingivitis (ANUG) 5 = Floor of the mouth
6 = Candidiasis 6 = Tongue
7 = Abscess 7 = Hard and/or soft palate
8 = Other condition (specify if possible) 8 = Alveolar ridges/gingiva
9 = Not recorded 9 = Not recorded