Oral Health Data Survey

Please answer the following questions to the best of your ability.

Date: *

Texas County: *

Age Range: *

Gender: *

Male

Female

Unknown

Race: *

Ethnicity: *

Non-Hispanic

Hispanic

Unknown

Insurance Status: *

Medicaid/CHIP

Private

Uninsured

Unknown

Length of time since last dental visit: *

Last year

1-2 years

2+ years

Never

Length of time since last dental visit: *

Untreated Decay (presence of at least one dental cavity in primary (baby) or permanent teeth): *

With Untreated Decay

Without Untreated Decay

Unknown

Previously Treated Decay (e.g. restoration, filling, crown, or fixed prosthetics): *

With Treated Decay

Without Treated Decay

Unknown

Early Childhood Caries (ECC): *

With ECC

Without ECC

Unknown

Existing Sealants on First Permanent Molar Teeth: *

With Existing Sealants

Without Existing Sealants

Unknown

Sealant Placement *

Received at Least One Sealant

Did Not Receive A Sealant

Denture Use (presence of either partial or full removable denture): *

Uses Dentures

Does Not Use Dentures

Number of natural teeth in the upper arch (maxillary): _____ (count the number of teeth) *

Number of natural teeth in the lower arch (mandibular): _____ (count the number of teeth) *

During last dental visit were you diagnosed needing periodontal care (periodontal therapy includes scaling and root planing or surgery): *

Need Periodontal Care

Do Not Need Periodontal Care

Unknown

Treatment Urgency: *

No Obvious Problem

Early Treatment

Urgent Treatment

Unknown

Fluoride Varnish application during last dental visit: *

Received Fluoride

Didn’t Receive Fluoride

Unknown

During your last dental visit did you receive Prophylaxis (Prophy=teeth cleaning): *

Received Prophy

Didn’t Receive Prophy

Unknown

Oral Health Instruction (OHI): *

Received OHI

Didn’t Receive OHI

Unknown

During last dental visit did you receive restorative care or dental surgery: *

Received Restorative Care

Didn’t Receive Restorative Care

Unknown

Other Dental Care: *

Received Other Dental Care

Didn’t Receive Other Dental Care

Unknown

During the past 12 months, how many times have you gone to a hospital emergency room for dental problem? Do not count visits for injury or trauma. *

BSS indicator descriptions:

PK = preschool children, SA = school age children, AD = adults

Untreated decay (PK, SA, AD): presence of active caries in primary and permanent dentition

Treated decay (PK, SA, AD): previously treated decay (e.g. restoration) in primary and permanent dentition. This category also includes fixed prosthetics, including crowns and restored implants.

Existing sealants (SA): sealants (either full or partial) that are present on permanent molar teeth. Exclude sealants on non-molar permanent teeth or on the primary dentition

Early childhood caries (PK): presence of caries on the six maxillary primary anterior teeth. For the BSS, mandibular anterior teeth are not included

Denture use (AD): presence of either partial or full removable dentures

Number of natural teeth upper arch (AD): the number of natural teeth present in the upper arch

Number of natural teeth lower arch (AD): the number of natural teeth present in the lower arch

Need for Periodontal Care (AD): patient needs periodontal treatment (dental prophylaxis or other periodontal therapy) before the next dental visit

Treatment Urgency (PK, SA, AD):

No obvious problem: there are no visible dental problems, routine care recommended

Early treatment: a dental problem is present and should be addressed within the next six months

Urgent treatment: pain or infection is present and the dental problem needs to be addressed immediately

Other Dental Care: any other dental service not included in the specific service responses. “Other Dental Care” includes services that you believe are important to disseminate, but are not routinely included in ROHDEO (e.g. case management).

1
2-3
4-5
6-7
8-9
10-12
13-15
16+
No teeth
Don’t know/not sure
None/0
Refused