Gum Diseases Risk Assessment

Kigo Dental - Self Assessment form for risk of developing gum diseases.

The following is a self-assessment to help you identify factors that indicate you may develop gum diseases in future. The assessment is meant to be informative but does not substitute for a comprehensive evaluation by your dentist or healthcare provider to determine your actual risk and condition.

Gum Disease

Be sure to answer all the questions honestly to obtain an accurate score. Hereafter "you" can be related to you, your child, or any person in need of taking this test.

1. How often do you brush your teeth?

Two or more times a day One time a day Less than one time a day

2. Do your gums appear red, purple, or swollen?
Yes No

3. Are you experiencing pain, discomfort or bleeding while brushing your teeth?
Yes No

4. Are your gums receding or making the appearance of your teeth longer?
Yes No

5. Have you noticed dark spaces or gaps between your teeth?
Yes No

6. Have you noticed that your teeth are loose or that your bite has changed recently?
Yes No

7. Has a dentist, periodontist or healthcare professional ever told you that you have “deep pockets” around your teeth?
Yes No

8. Do you smoke or use any tobacco products, alcohol or recreational drugs?
Yes No

9. Do you have any medical conditions that may affect your dental health, such as diabetes, heart disease, or immune system disorders? Have you undergone chemotherapy or radiation therapy?

No Yes, but it is well-controlled Yes, and it is not well-controlled

10. Are you pregnant?
Yes No

11. Do you have a family history (parents or siblings) of gum disease or early tooth loss?
Yes No

12. How often do you get dental cleanings done?
Once a year
Twice a year
Every three months
It has been two or more years since my last dental cleaning
Never got dental cleaning done

13. Do you have any teeth extracted or missing due to loosening of teeth in past 36 months?
Yes No

14. Do you have any visible plaque or discolouration on your teeth?
Yes No

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Note: Please note that this self-assessment form does not intend to provide a definitive diagnosis if you will develop gum disease or other health conditions; it is designed to give you approximate knowledge about factors that may contribute to gum disease so that you can get appropriate consultation. Consulting with a qualified healthcare professional is mandatory to get a definitive diagnosis.

Gum Diseases Risk Assessment

Kigo Dental - Self Assessment form for risk of developing gum diseases.

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