European Global Oral Health Indicators Development II Full Standard Clinical Survey Form — 2008 v22 Date of Examination Dentist ID Country Code Patient Information OO Oo Ago (ast bithday) Sex (em 2=F ime since last dental examination Choose the nearest from the options given to indicate the interval since last examination. thant year Oo ethan 1 year but ss than 2 years ee than 2 years but ess than 8 years ere than 8 years ver previously been examined known oF rhse (0 S3y Does the patient brush with fluoride toothpaste? [_] 0») date as day / month / year 00 OO OOo OO Place of residence ‘What is the postcode at the patient's home address? ae) Is the patient able to reach a dentist, when needed, within 30 minutes travel from home or employment? Dos Place 'in this boxif not known (07) tyes 2=n0 x= ort know /not sure tyes 2210 x= donit know /not sure How many eatingldrinking occasions do you have per day even in small quantities [J] to Patient's or (for child) Mother's highest education level lever attended school or kingergarion only What has been the patient's or parent's employment status during the past twelve months? Patient smokes? Oe Patient consumes alcoholic beverages? [J (14) Key to ages (used next to each indicator) Baa] FAs ic An Child aged 1 to 5 4 yy Child aged 6 to 14 Nn JAR RRs ‘Adults and children i ] i Oe Grades 9 10 11 (attended high schoo! Grades 12 or GED (graduated at high schoo) 5 College for 1 10 3 years (attended college) CColege 4 or more years (college graduate) iot known / not eure /urwaling to ay 5 = Seitemplayed 6 = Home maker 7=Reties x= Not recorded 3= Student 4 Unable to work {ter the code according fo the key for smoking and alcatel usage) 1 = every day 3 never 2= some days xc unable / unin to say Child aged 42 only Oh ‘Adults onlyDENTAL DISEASE ASSESSMENT 1. Examine the patient and fill out the charts: or tick the single box if edentulous. Edentulous Dos (tok the box and continue to 07) ‘Restoration and Sealant Codes (0 Not seals or restored 1 = Sealant, paral 25 Sealant fu 3 = Tooth coloured restoration 4+ Amalgam estoraion| = Stainless crown 6 Pexelin, gol PFM crown or veneer 7= Lest or broken restoration B= Temporary restoration ‘A Big code should Caries Codes ‘Sound tooth surface Fist visual change in ena 2 = Disinet visual ebange i earl 3 = Enamel breakdown, no dentine visible 4 = Dental shadows (ot caviated int dentine) 5 = Disine cavity with vise denne 6 = Extensive distinct cavity with visbe deine Missing Testh 97 Exaacied due to caries 98. Mising for other reason 58 Unenged| he, Swedes soe P= Missing tot replaced by implant or bier i‘ ‘dicted pontic Allages Upper Right [Pri Upper Left 2) 7 & | Permanent dentition Lower Right [Primary dentition In chil circle the teeth presei Lower Left £ ar ’ @ Permanent dentition | ORTHODONTIC TREATMENT COVERAGE 2. Does the person claim to wear a fixed or removable orthodontic appliance? 5to 17 [ite 2368 2en0 473. Gauge the level of dental fluorosis (whole mouth); [J«7) 4 = None (normal enamel) 2 Questionable 3=-Very mid anni 5: Moserate = severe x= Not applicable 4 Has the patient daily or regularly used a fluoridated product other than toothpaste? — Js) yes 2=n0 x= dont know ifyes, list those used using the key. 1) (J Cy yyy jorge tablets or drops a nse 2 = furiated pub water 5 fuondated sat $= fuosidated bottled water her products| x= not known J unwiling to say REMOVABLE DENTURE PREVALENCE 5, Does the person claim to wear dentures? Clas tyes +00 PERIODONTAL HEALTH ASSESSMENT AND PERIODONTAL DISEASE SEVERITY On the chart below please indicate the following: 6. Provide @ Community Periodontal Index (CPI) score for each sextant from the following list Bleeding X —_Exchded seta oss than two teeth present) Caieus 9 ‘Notrecorded 12 to 74] Pocket 5mm + Record bleeding only in 12 and 15-year-olds: do not probe for pocket depth “Note: In line with the recommendations of an expert panel of EGOHID associates, calculus is not included in the definition of the indicator and itis therefore recommended that this coding is not used at any age. 7. How severe is the loss of attachment (LOA) around the whole mouth? (Si sites per tooth) Heathy 0 mm. 3 Severe Sem ormore Sight * 12mm. 9 Notrecorded Moderate $ ord mm Toa 6 Toot 6 Tal T Bue Co cri ti ty If tooth is missing, please record this by scoring out the appropriate tooth number lke thisLESIONS OF THE ORAL MUCOSA ane 8, Please incicate it any suspicious growths or conditions are noted. — [] % he {3510 64) Where the clinician has ticked the box, please provide some additional information in the boxes below. Enter codes {rom the list provided in the guidance (reproduced below for reference) Condition Choose from the following conditions: _ ‘Malignant tumour (oral cance Leukopiakia Lichen planus Ulceration (aphthous, herpetic, traumatic) Enythropiakia (Other or not sure IFother’, please specify ‘Thank you for completing this form, Please Return to: Harling Comune ProecionDinconecaent + ECOHID Hl Community Action Programme on Health Monitoring =" * * *