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Patient’s Name Last First Initial
_________________________ Date of Birth _________________________ 1. Purpose of initial visit _________________________ 2. Are you aware of a problem? _________________________ 3. How long since your last dental visit? _________________________ 4. What was done at that time? _________________________ 5. Previous dentist’s name Address: Tel. _________________________ 6. When was the last time your teeth were cleaned? _________________________ CIRCLE THE APPROPRIATE ANSWER. IF YOU DON’T KNOW THE CORRECT ANSWER, PLEASE WRITE “DON’T KNOW” ON THE LINE AFTER THE QUESTION. 7. Have you made regular visits? _________________________ How often: _________________________ 8. Were dental x-rays taken? _________________________ 9. Have you lost any teeth or have any teeth been removed? _________________________ Why? _________________________ 10. Have they been replaced? _________________________ 11. How have they been replaced? _________________________ a. Fixed bridge Age b. Removable bridge Age c. Denture Age d. Implant Age 12. Are you unhappy with the replacement? _________________________ If yes, explain 13. Would you like to know about permanent replacements? _________________________ 14. Have you ever had any problems or complications with previous dental treatment? _________________________ If yes, explain: 15. Do you clench or grind your teeth? _________________________ 16. Does your jaw click or pop? _________________________ 17. Have you experienced any pain or soreness in the muscles or your face or around your ear? _________________________ 18. Do you have frequent headaches, neckaches or shoulder aches? _________________________ 19. Does food get caught in your teeth? _________________________ 20. Are any of your teeth sensitive to: ?? Hot? _________________________ Cold? ?? Sweets? ?? Pressure? 21. Do your gums bleed or hurt? _________________________ When? 22. Do you experience dry mouth? _________________________ 23. How often do you brush your teeth? When? _________________________ 24. Do you use dental floss? _________________________ How often? 25. Are any of your teeth loose, tipped, shifted or chipped? _________________________ 26. Are you unhappy with the appearance of your teeth? _________________________ 27. How do you feel about your teeth in general? _________________________ 28. Do you feel your breath is offensive at times? _________________________ 29. Have you ever had gum treatment or surgery? _________________________ What? Where? When? 30. Have you had any orthodontic work? _________________________ 31. Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike? _________________________ 32. Do you have any questions or concerns? _________________________ Do you have loose or missing teeth? _________________________ Do your gums bleed on brushing or eating? _________________________ Does food catch between your teeth? _________________________ Have your teeth shifted, are there spaces between your teeth now where there were none, are your teeth flaring, or are some of your teeth becoming loose? _________________________ Are any of your teeth sensitive to heat, cold, or pressure? _________________________ Do you grind your teeth or clench your jaws? _________________________ Do you have pain or clicking in the jaw joint in front of your ear? _________________________ Have your jaw muscles ever been sore? _________________________ If yes, describe. _________________________ Are there any sores or growths in your mouth? _________________________ Do any of your teeth ache? _________________________ _ Do you have any other dental complaint? _________________________ Do your gums bleed when brushing, flossing or eating? _________________________ Do you have difficulty brushing or flossing an area? Does food collect between your teeth? _________________________ Do you have a bad taste or odor in your mouth? _________________________ Do you have any loose teeth, or have any teeth moved or shifted within the past two years? _________________________ Do you or have ever smoked? (packs/day:_____) When did you quit? _________________________ Have you ever been diagnosed or treated for periodontal disease? Any family history? _________________________ Do you floss, use a water jet device, interdental stimulator, or proxy brush? _________________________ Do you have toothaches, sore teeth or dental pain? _________________________ Are your teeth sensitive to hot, cold, sweets, biting, or touch? _________________________ Do you have any broken teeth, missing fillings, or root canals? _________________________ Do you have a dry mouth? _________________________ Do you drink fluoridated water or take fluoride supplements? _________________________ Have you had cavities diagnosed or treated within the past two years? _________________________ Do you clench or grind your teeth? Are you awake or asleep when it occurs? _________________________ Do you have soreness or pain in your jaw, ear, or side of your face? _________________________ Do your get frequent headaches? _________________________ Does your jaw ever pop, click, lock, or become fatigued or tired? _________________________ Do you have difficulty opening, closing, or chewing certain types of foods, i.e. gum or bagels? _________________________ Do your teeth come together unevenly or do you hit one tooth before the others when you bite? _________________________ Do you wear a splint, night guard or had an injury to the head/neck including an auto accident? _________________________ Have your teeth changed in the last 5 years? Do they appear shorter? _________________________ Are you dissatisfied with the appearance of your teeth? _________________________ Do you dislike the color of your teeth or have noticeable spots or stains? _________________________ Do you have existing crowns or dental work, which you consider “ugly”? _________________________ Do you have chips, spaces, crowded or crooked teeth that bother you? _________________________ Are you self-conscious of your teeth or smile or has anyone suggested you change your smile? _________________________ Would you like to improve your smile? _________________________ Have you ever had complications from past dental treatments? _________________________ Have you experienced any complications or reactions from local anesthetic? _________________________ Have you ever had teeth extracted? _________________________ Did you ever have braces or orthodontic treatment? _________________________ Do you have any lumps, sores, or growths in your mouth? _________________________ Does dental treatment cause you much worry or concern? _________________________ Have you had an unpleasant dental experience in the past? _________________________ Do you think your teeth are affecting your general health? _________________________ I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE PATIENT NUMBER Patient’s Name Last First Initial Date of Birth _________________________ Periodontal (Gum) Disease Do you have loose or missing teeth? What causes gum disease? Our mouths are full of bacteria. These bacteria, along with mucus and other particles, constantly form a sticky, colorless “plaque” on teeth. Brushing and flossing help get rid of plaque. Plaque that is not removed can harden and form “tartar” that brushing doesn’t clean. Only a professional cleaning by a dentist or dental hygienist can remove tartar. Gingivitis The longer plaque and tartar are on teeth, the more harmful they become. The bacteria cause inflammation of the gums that is called “gingivitis.” In gingivitis, the gums become red, swollen and can bleed easily. Gingivitis is a mild form of gum disease that can usually be reversed with daily brushing and flossing, and regular cleaning by a dentist or dental hygienist. This form of gum disease does not include any loss of bone and tissue that hold teeth in place. Periodontitis When gingivitis is not treated, it can advance to “periodontitis” (which means “inflammation around the tooth”). In periodontitis, gums pull away from the teeth and form spaces (called “pockets”) that become infected. The body’s immune system fights the bacteria as the plaque spreads and grows below the gum line. Bacterial toxins and the body’s natural response to infection start to break down the bone and connective tissue that hold teeth in place. If not treated, the bones, gums, and tissue that support the teeth are destroyed. The teeth may eventually become loose and have to be removed. Risk Factors Smoking. Need another reason to quit smoking? Smoking is one of the most significant risk factors associated with the development of gum disease. Additionally, smoking can lower the chances for successful treatment. Hormonal changes in girls/women. These changes can make gums more sensitive and make it easier for gingivitis to develop. Diabetes. People with diabetes are at higher risk for developing infections, including gum disease. Other illnesses. Diseases like cancer or AIDS and their treatments can also negatively affect the health of gums. Medications. There are hundreds of prescription and over the counter medications that can reduce the flow of saliva, which has a protective effect on the mouth. Without enough saliva, the mouth is vulnerable to infections such as gum disease. And some medicines can cause abnormal overgrowth of the gum tissue; this can make it difficult to keep teeth and gums clean. Genetic susceptibility. Some people are more prone to severe gum disease than others. Who gets gum disease? People usually don’t show signs of gum disease until they are in their 30s or 40s. Men are more likely to have gum disease than women. Although teenagers rarely develop periodontitis, they can develop gingivitis, the milder form of gum disease. Most commonly, gum disease develops when plaque is allowed to build up along and under the gum line. How do I know if I have gum disease? Symptoms of gum disease include: Bad breath that won’t go away Red or swollen gums Tender or bleeding gums Painful chewing Loose teeth Sensitive teeth Receding gums or longer appearing teeth Deep Cleaning (Scaling and Root Planing) The dentist, periodontist, or dental hygienist removes the plaque through a deep-cleaning method called scaling and root planing. Scaling means scraping off the tartar from above and below the gum line. Root planing gets rid of rough spots on the tooth root where the germs gather, and helps remove bacteria that contribute to the disease. In some cases a laser may be used to remove plaque and tartar. This procedure can result in less bleeding, swelling, and discomfort compared to traditional deep cleaning methods. Medications Medications may be used with treatment that includes scaling and root planning, but they cannot always take the place of surgery. Depending on how far the disease has progressed, the dentist or periodontist may still suggest surgical treatment. Long-term studies are needed to find out if using medications reduces the need for surgery and whether they are effective over a long period of time. Listed on the next page are some medications that are currently used. How can I keep my teeth and gums healthy? Brush your teeth twice a day (with a fluoride toothpaste). Floss regularly to remove plaque from between teeth. Or use a device such as a special brush or wooden or plastic pick recommended by a dental professional. Visit the dentist routinely for a check-up and professional cleaning. Don’t smoke Can gum disease cause health problems beyond the mouth? In some studies, researchers have observed that people with gum disease (when compared to people without gum disease) were more likely to develop heart disease or have difficulty controlling blood sugar. Other studies showed that women with gum disease were more likely than those with healthy gums to deliver preterm, low birth weight babies. But so far, it has not been determined whether gum disease is the cause of these conditions. There may be other reasons people with gum disease sometimes develop additional health problems. For example, something else may be causing both the gum disease and the other condition, or it could be a coincidence that gum disease and other health problems are present together. More research is needed to clarify whether gum disease actually causes health problems beyond the mouth, and whether treating gum disease can keep other health conditions from developing. In the meantime, it’s a fact that controlling gum disease can save your teeth – a very good reason to take care of your teeth and gums. |