Patient name : File #

Age : Date of Evaluation

ATTITUDE & DISEASE STATUS DISEASE STATUS

ATTITUDE (Patient Self Assesment) 1 2 3

Are you willing to change the way you care for oral health?
YES = A MAYBE = B NO = C A

EDUTITTA
DISEASE STATUS (Clinicial Assesment B
1 = No current disease
2 = Need for repair, maintanance C
3 = Active disease

SALIVA
RESTING SALIVA STIMULATED SALIVA
HYDRATION VISCOSITY pH QUANTITY pH BUFFERING
> 60 sec Sticky/stringy 5.0-5.8 < 3.5 ml 5.0-5.8 0-5 points

30-60 sec Frothy/bubbly 5.8-6.8 3.5-5.0 ml 6.0-6.5 6-9 points

< 30 sec Watery/clear 6.8-7.8 > 5.0 ml 6.8-7.8 10-12 points

PLAQUE BACTERIA DIET # of exposure in between meals

PLAQUE pH PLAQUE Maturity S. MUTANS Count SUGAR ACID

5,5 BLUE STAIN > 500.000 >2 >3

6.0-6.5 >1 >2

7.0 RED STAIN < 500.000 NII <2

FLUORIDE
YES NO Do you use fluoride toothpaste? 0 YES

YES NO Any fluoride in drinking water? 1-2 YES

YES NO Received professional fluoride treatment? 3 YES

MODIFYING FACTORS DIVA DIVA

ID
AV

DIVA

YES NO Any drugs which can decrease salivary flow? specify ≥ 1 YES
YES NO Any disease which can caus dry mouth? specify
YES NO Any fixed or removable prosthesis, including orthodontic appliances? specify
= 5 NO
YES NO Is compliance likely to be poor?
YES NO Does patient have a recent episode of active caries?
DIVA

SALIVA
PLAQUE
OVERALL BACTERIA
TRAFFIC LIGHT DIET
ASSESSMENT FLUORIDE
MODIFYING FACTORS