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WHO ORAL HEALTH ASSESSMENT FORM

(Modified from WHO Oral Health Proforma 2004)


ID number Name:

Age in years Special need condition specify-------------------------------------------
Sex (M = 1 ! = "# $ccupation of parent% primary careta&er
' = Non s&illed (or&er ()eon *abourer !armer# 1 = S&illed (or&er (+arpenter Mason# " = )rofessional
, = -usinessman . = /ouse(ife 0 = Sc1ool going c1ild 2 = Non sc1ool going c1ild 3 =
4 = Non-employed 5 = No a6ailable information
EXTRA-ORAL EXAMINATION
' = Normal extra-oral appearance
1 = 7lceration sores erosions fissures (1ead nec& limbs#
" = 7lceration sores erosions fissures (nose c1ee&s c1in#
, = 7lceration sores erosions fissures (commissures#
. = 7lceration sores erosions fissures (6ermillion border#
0 = +ancrum oris
2 = Abnormalities of upper and lo(er lips
3 = 8nlarged lymp1 nodes (1ead nec&#
4 = $t1er s(ellings of face and 9a(s
5 = Not recorded
DENTITION STATUS STATUS
00 0. 0, 0" 01 21 2" 2, 2. 20
14 13 12 10 1. 1, 1" 11 "1 "" ", ". "0 "2 "3 "4

40 4. 4, 4" 41 31 3" 3, 3. 30
.4 .3 .2 .0 .. ., ." .1 ,1 ," ,, ,. ,0 ,2 ,3 ,4
Status



Score +riteria
'
No or slig1t c1ange in enamel
transluscency after prolonged air
drying (0s#
1 !irst 6isual c1ange in enamel (after
prolonged air drying or restricted
to (it1in t1e confines of a pit or
fissure
" Distinct 6isual c1anges in
enamel
, *ocali:ed enamel brea&do(n in
opa;ue or discoloured enamel
((it1out 6isual signs# of dentinal
in6ol6ement
. 7underlying dar& s1ado( from
dentin
0 Distinct ca6ity (it1 6isible
dentin
2 8xtensi6e distinct ca6ity (it1
6isible dentin ( in6ol6ing more
t1an 1alf of t1e surface#
-
("4#
U =s1arp edges of a u
dislocated toot1 (it1 pulp
in6ol6ement or root
fragments 1a6e caused
traumatic ulceration
of t1e surrounding
soft tissue
F = pus releasing sinus f
tract related to a toot1
(it1 pulp in6ol6ement
is present
A = pus containing a
s(elling related to a
toot1 (it1 pulp
in6ol6ement is present
P = opening of t1e pulp p
c1amber is 6isible or
(1en t1e coronal
toot1 structures 1a6e
been destroyed by
t1e carious process
and only t1e roots or
root fragments
are left
ORAL HYGIENE STATUS (OHI S)




FLUOROSIS
' = Normal
1 = <uestionable
" = =ery mild
, = Mild
. = Moderate
0 = Se6ere
4 = 8xcluded
5 = Not recorded

.2 ,1 ,2
40 31 30
DEBRIS INDEX SIMPLIFIED
Sco!" #$%!$a
' No debris or stain present
1 Soft debris co6ering not more t1an one t1ird of t1e
toot1 surface or presence of extrinsic stains (it1out
ot1er debris regardless of surface area co6ered
" Soft debris co6ering more t1an one t1ird but not more
00 01 20
12 11 "2
#AL#ULUS INDEX SIMPLIFIED
Sco!" #$%!$a
' No calculus present
1 Supragingi6al calculus co6ering not more t1an t1ird of t1e
exposed toot1 surface>
" Supragingi6al calculus co6ering more t1an one t1ird but not
more t1an t(o t1irds of t1e exposed toot1 surface or t1e
presence of indi6idual flec&s of subgingi6al calculus around
t1e cer6ical portion of t1e toot1 or bot1>
+I -S score
DI -S score
.2 ,1 ,2
40 31 30
00 01 20
12 11 "2
NEED FOR IMMEDIATE #ARE
*ife t1reatening condition
?a(s fracture
)ain or infection
@eferral to care
' = Absent
1 = )resent%referral
FLUOROSIS
DENTOFA#IAL ANOMALIES
D8NAIAI$N
Missing incisor canine and premolar teet1Bmaxillary and mandibularBenter number of teet1
S)A+8
+ro(ding in t1e incisal segments: spacing in t1e incisal segments Diastema in mm
' = No cro(ding ' = No spacing
1 =$ne segment cro(ding 1 = $ne segment spaced
" =A(o segments cro(ding " = A(o segments spaced
*argest anterior maxillary irregularity in mm *argest anterior mandibular irregularity in mm
$++*7SI$N
Anterior maxillary Anterior mandibular =ertical anterior Antero-posterior
$6er9et in mm o6er9et in mm openbite in mm molar relation

' = Normal
1 = /alf cusp
" = !ull cusp
E&%!'% of (!f!c%
1" 11
"1 ""
.2 ".
1. ,2
1" 11
"1 ""
.2 ".
1. ,2
#ODES FOR THE DDE INDEX
No)a*
'
D!)aca%!( opac$%$!":
(1ite%cream
1
yello(%bro(n
"
D$ffu"! opac$%$!"+
Diffuse - *ines
,
Diffuse - )atc1y
.
Diffuse - +onfluent
0
+onfluent%patc1y C stainingC loss of enamel
2
H,pop*a"$a+
)its
3
Missing 8namel
4
Any ot1er defects
5
E&%!'% of D!f!c%
Normal
'
D1%,
1
at least 1%, D "%,
"
at least "%,
,
ENAMEL HYPOPLASIA (DDE INDEX)
' = Normal
1 = <uestionable
" = =ery mild
, = Mild
. = Moderate
0 = Se6ere
4 = 8xcluded
5 = Not recorded

GENERAL HEALTH PROFORMA
Name: $)D No>:
Age: Eender: Identification No>:
Address:
Diagnosis:
F1et1er undergone c1emot1erapy%radiot1erapy% surgery G
Date of c1emot1erapy% radiot1erapy%surgery:
)ost Areatment $utcome:
Medication presently ta&en:
$ral 1ygiene measures:
Aid of teet1 cleaning:
Agent for teet1 cleaning
!re;uency:
F1et1er using flossG

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