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AM I AT RISK FOR DEVELOPING GUM-RELATED PROBLEMS?

Complete self-exam and find out!

Thank you for completing self-exam. Congratulations!

You may be at low-risk for gum-related problems. Keep up the good work!

Thank you for completing self-exam. Be careful!

You may be at higher risk for gum-related problems. Speak to your dentist about a potential condition and its consequences.

Do your gums bleed when you brush your teeth?

Yes No

Have you been told by a dental professional that you have bone loss around your teeth?

Yes No

Have any teeth become loose (not due to a tooth trauma)?

Yes No

Have you had 7 or more permanent teeth extracted because of decay, looseness, or pain? (not counting wisdom or impacted teeth, or teeth knocked out by an accident or removed for orthodontics)

Yes No

Have you had or are you currently scheduled for a deep cleaning (scaling & root planing)?

Yes No

Have you had or are you currently scheduled for gum surgery (periodontal surgery)?

Yes No

The frequency that I use dental floss or another device to clean between my teeth is:

Never Daily Occasionally

The number of periodontal maintenance appointment(s) I have had in the last 24 months is: (exclude normal teeth cleaning appointments)

None/Don’t know 1-2 3-4 >5

What is your diabetic status?

Not Diabetic Diabetic, well controlled Diabetic, not controlled Diabetic, unknown control

Do you smoke cigarettes?

Never Former User < 1 pack per day 1 pack per day or more

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