QUESTIONNAIRE

Topic: Relationship between awareness of periodontal disease and good oral health
status of NYP Dental Hygiene and Therapy (DHT) students in 2016

Age: ________

Gender: M / F

1. Are you aware of periodontal disease?

Y/N

2. Did you notice any swelling and/or bleeding?

Y/N

3. Any prostheses (crown, bridge, implant, denture, retainer) worn?

Y/N

a. If yes, why was it placed? (e.g. trauma, decay etc.): ______________

4. Did you notice any signs of bad breath?

Y/N

5. How do you clean your teeth?

Toothbrush & paste

Toothbrush & powder

Others (Datun,
Finger, Charcoal
powder)

6. How often do you brush your teeth each day?

1

Others: ________________

7. How many minute(s) do you brush your teeth for?

1

>4

8. How frequently do you change your brush?

< 3 months

3-6 months

> 6 months

9. What type of tooth brushing movements do you employ?

Horizontal

Vertical

Combined

10. Do you use mouthwash?

Y/N
a. If yes, then how often and what is the brand? _______________
b. Reason: _______________________________________________
11. Which secondary methods for plaque control do you use?
Dental floss

Interdental
brushes

Toothpicks

a. If yes, then how often? _________________

None

12. Do you use a tongue cleaner?

Y/N

13. On what is your daily diet based?

Vegetables

Carbohydrates
(e.g. Potato
chips, rice etc.)

Milk proteins

Meat

14. When was your last dental checkup?

< 6 months

Within past
6-12
months

Between last
1-2 years

> 2 years

15. Reasons for dental checkup?

Pain in tooth
Whitening

Regular dental checkups

To remove bad breath

Others: _____________________________

Section to be filled by Clinician:

1. Tooth brushing technique: Roll / Scrub / Bass / Combined
2. Oral Hygiene Status of Patient:

3. Plaque

Good / Fair / Poor