PREFORMA FOR PREVALENCE OF ORAL HABITS

AWADH DENTAL COLLEGE AND HOSPITAL

DEPARTMENT OF PEDODONTICS AND PREVENTIVE DENTISTRY

Assessment of knowledge, attitude and awareness among the parents of the school
going children regarding the prevalence of oral habits in Jamshedpur city.

PERSONAL INFORMATION
Registration number

 Name of school: ………………………………………………………

 Private

a) Primary b) Secondary

 Government
a) Primary b) Secondary

1) Name of student:

2) 2) Name of father:

3) Age:

4 ) Gender:

5) Profession of father:

6) ADDRESS:

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 Thumb sucking

1. Was the child breast fed or bottle fed up to 2 years or beyond 2 years? Breast fed Bottle-fed

2. Does your child suck his/her thumb or finger? Yes No

3. Since which age digit or thumb sucking was done?

4. Does he/she have a working mother or home-maker mother? W H

5. Was the child brought-up in day care home or at home? Day care Home

6. Which finger of the digit was sucked? i Thumb index finger Ring finger

7 . Manner digit was sucked? Horizontally Vertically

8. Duration of thumb sucking or finger-

9. Is the thumb sucking more during daytime or at night ? Stress Day Night

10. Was thumb sucking related to post having the second child? Yes No

On examination of the thumb/ index finger:

1. Whether there is callus formation? Yes No

2. Whether it was a clean finger nail or not? Yes No

TONGUE THRUSTING HABIT

1. Is the tongue protruded forward against the anterior teeth or not ? Yes No

2. Are the teeth in centric relation while swallowing? Yes No

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ON EXAMINATION:

Lip seal during swallowing: Yes No

Protrusion of upper anteriors: Yes No

MOUTH BREATHING HABIT:

a. Does your child suffer from adenoids or tonsillitis? Yes No

b. Presence of Upper Respiratory tract infections(URTI): Yes No

c. Does your child have deviated nasal septum (DNS): Yes No

d. Facial look/ Profile : Concave Straight Convex

e Presence of Gingival plaque on anterior teeth Healthy Gingivitis

f. Lip competency? Competent Incompetent

Diagnosis and examination of the mouth breathing habit:

SUBJECTIVE SYMPTOMS: History, Clues about nasal stuffiness, nasal discharge ,sore throat, repeated attacks of

cold.

OBJECTIVE SYMPTOMS: Hoarseness of voice, Malocclusion, restlessness at night, gingivitis and breathing problems

due to nasal blockade . Yes No

Mirror test: Positive Negative

Massler’s water holding test : Positive Negative

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Massler and Zwemer’s butterfly test / cotton test: +ve -ve

LIP HABITS :

History : 1)Whether any TMD ( Temporomandibular Joint Dysfunction ) present or not :

Yes No

2)Whether any teeth alignment issues (malocclusion) present or not : Yes No

a. On lip examination whether they were inflamed or not : Yes No

b. Dry or Chapped lips: Yes No

c. Bruxism: (TOOTH GRINDING DURING THE DAY): Yes No

d. Whether tooth was seen during normal jaw movements or not : Yes No

e. Whether there was masseter muscle hypertrophy on voluntary contraction: Yes No

 WHAT KIND OF HABIT MOSTLY SEEN?

 WHAT WAS THERE FREQUENCY?

 WHAT WAS THE DURATION?

NATURE OF THE PARENT:

IF BOTH PARENTS WERE PRESENT OR NOT:

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WHETHER ANY MEDICAL DISORDER WAS ASSOCIATED WITH THE CHILD OR NOT:

GENERAL APPEARANCE OF THE CHILD:

SIGNATURE OF THE PARENT: STAMP OF THE HEALTH COUNCIL

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