WHO ORAL HEALTH ASSESSMENT FORM (1997)

Country .
leave blank Year month Day Identification number Examiner Original/Copy

(1) 1 1 1 1 1 (4) (5) 1 1 1 1 1 (8) (9) [IJ (10) (11) 1 1 1 1 1 (14) 0(

15
Or (16)

GENERAL INFORMATION OTHER DATA (specify and indicate the keys)

Name . ................................................................................ 0(29)

Year month

Date of birth 0(
(17) 1 1 1 1 1 (20) Profession 0(3
25)
Age in years
(21) [IJ (22) Geographic location (26) CONTRAINDICATION FOR "
0)

THE EXAM
Sex (M = 1, F = 2)
0(23) Location type:
1 = Urban [IJ Reason: .................... . . . .. ... .. • .•••............ .. . . .
. ........... ... .
Ethnic group 0(
2 = Periurban (27)
0(24)
3 = Rural 31
0(
28 )
)
O

= No
1 = Yes

7= 8 = Other swellings of the face and jaw

(commissures) Enlarg 9 = Not registered
4 = Ulcers, sores, inflammations, erosions, fissures ed
lymph
(vermilion border)
nodes
5 = Oral cancer (head,
6 = Anomalies of the upper or lower lips neck)
Or (32) 0(
33
)
(<30mm
opening)

CLINICAL EVALUATION

1 = Ulcers, inflammations, erosions, fissures SYMPTOMS SIGNS

1 = Yes 1 = Yes Click

9 = Not recorded 9 = Not recorded Pain on palpation
Reduced mobility of the jaw
ORAL MUCOSA

DISORDER LOCATION
O = No abnormal state O = Vermilion border
1 = Malignant tumor (oral cancer) (37)0 (38)0 0( 1 = Commissures
2 = Leukoplakia 40 2 = Lips
=
3 Lichen planus (39)0 )
3 = Furrows
4 = Ulcer (aphthous, herpetic , traumatic) 4 = Oral mucosa
5 = Acute necrotizing gingivitis 0(
5 = Floor of mouth
6 = Candidiasis 41
) 6 = Language
7 = Abscess 7 = Hard and / or soft palate
0(
42
)
=
8 Other disorder (specify if possible) . 8 = Alveolar ridges / gums
9 = Not registered 9 = Not registered

ENAMEL OPACITIES/HYPOPLASIA DENTAL FLUOROSIS

(43)0
permanent teeth 14 13 12 11 21 22 23 24
O= Normal O= Normal
1 = Bounded Opacity 1 1 1 1 LJ(50) 1 = Debatable
1 2 = Very light
2 = Diffuse opacity 0(53)
(51) LJ(5
3 = Hypoplasia 3 = Light
46
4 = Other defects 2) 4 = Moderate
5 = Delimited and diffuse opacity 36 5 = Intense
6 = Delimited opacity and hypoplasia 8 = Excluded
7 = Diffuse opacity and hypoplasia 9 = Not registered
8 = The three alterations
9 = Not registered

COMMUNITY PERIODONTIC INDEX (CPI) LOSS OF FIXATION*

17/16 11 26/27 17/16 11 26/27
O = Healthy
1 = Hemorrhage (54)�(56)
O= 0-3mm
1 = 4-5 mm (cementum-enamel junction (CEJ) inside the black band) (60) ITIJ (62) (63)
2 = Calculation
3* = 4-5mm bag (black probe band (57) ITIJ (59)
2 = 6-8 mm (UCE between the super limitior of the band
ITIJ (65)
partially visible) black and the ring of 8 , 5 mm)
47/46 31 47/46 31 36/37
36/37
4• = Pocket of 6 mm or more (black band on the probe • Not registered in children under 15 years of age .
invisible)
X = sextant excluded
9 = Not registered
3 = 9-11 mm (UCE between 8.5 mm and 11.5 mm rings)
4 = 12 mm or more (UCE
beyond 11.5 mm annulus) X =
Sextant excluded
9 = Not registered

• Not registered in children under 15 years of age