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Rate Your Oral Health

The following questions will help you realize if you are in good dental health or not. Please be informed this is only a self-assessment and does not replace your regular visit to the dentist. Semi-annual checkups in the following areas are highly recommended: Head and Neck exam, Temporal Mandible Joint exam, Intra-oral soft tissue cancer screening, 6-point periodontal measurement, detailed exam of each tooth, dental photos, and dental x-ray (3D Conebeam CT scan may be needed)

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(Count the number of “yes” answers to help you determine your possible risk in each of the areas.)

Your Gums/Bone

    • Do you have a bad taste or odor in your mouth?

    Please make a selection.

    • Do you have plaque and tartar on your teeth?

    Please make a selection.

    • Do your gums bleed when you brush or floss your teeth?

    Please make a selection.

    • Do you have receding gum line?

    Please make a selection.

    • Do you have a tooth that is loose or shifting?

    Please make a selection.

    • Have you lost any teeth due to gum disease?

    Please make a selection.

    • Do you smoke cigarettes, cigars or vaping?

    Please make a selection.

    • Do you have any of the following diseases: diabetes, cardio-vascular disease (high blood pressure, heart disease) or any inflammatory disease?

    Please make a selection.

Your Teeth

    • Do you have black or brown stains on your teeth?

    Please make a selection.

    • Do you have chips or broken teeth or holes in your teeth?

    Please make a selection.

    • Do you have broken fillings, crowns, bridges or dentures?

    Please make a selection.

    • Do you have difficulty swallowing due to dry mouth?

    Please make a selection.

    • Do you have GERD or a sour taste in the mornings?

    Please make a selection.

    • Are your teeth SENSITIVE to cold/hot/sweets or chewing?

    Please make a selection.

    • Do you get food caught between your teeth after you eat?

    Please make a selection.

    • Do you have “a sweet tooth” and drink sweet drinks daily, snack frequently or eat candy frequently?

    Please make a selection.

Your Bite

    • Do you have frequent headaches, neck pain or jaw pain?

    Please make a selection.

    • Do your jaw joints make sounds on movement?

    Please make a selection.

    • Do you notice that your front teeth are wearing down or chipping away while your back teeth are in good condition?

    Please make a selection.

    • Do you find your teeth short and flat?

    Please make a selection.

    • Do you have difficulty chewing?

    Please make a selection.

    • Do you have a bad bite, or your teeth do not come together well?

    Please make a selection.

    • Do you clench or grind your teeth?

    Please make a selection.

    • Do you bite your fingernails, chew ice or other objects?

    Please make a selection.

Your Smile

    • Do you feel that your teeth are NOT as white as they should be?

    Please make a selection.

    • Do you have mismatched colored crowns/teeth that bother you?

    Please make a selection.

    • Are you concerned with the appearance of the misaligned and overlapping of your teeth?

    Please make a selection.

    • Do you have missing teeth that are visible when you talk or smile?

    Please make a selection.

    • Are you embarrassed to smile?

    Please make a selection.

    • Do you have a gummy smile that you dislike?

    Please make a selection.

Your Sleep

    • Are you having difficulty sleeping through the night?

    Please make a selection.

    • Do you snore and/or choke during your sleep?

    Please make a selection.

    • Do you fall asleep at any given chance you get?

    Please make a selection.

    • Do you frequently fall asleep watching TV?

    Please make a selection.

    • Are you overweight (BMI 30+)?

    Please make a selection.

    • Is your neck size equal or larger than 17 inches for a man and 16 inches for a woman?

    Please make a selection.
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