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Total Health Checklist:Layout 1 9/13/11 10:45 AM Page 1 Total Health Checklist This information will assist the dental professionals in assessing both your oral health and its impact on your overall health. Please answer completely to the best of your knowledge. Patient Name (Last Name, First Name) _____________________________________________________________________ Height_____________ Weight_____________ How frequently have you been brushing your teeth?_________________________________________________________ SA How frequently have you been flossing your teeth?__________________________________________________________ Do your gums bleed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Are your gums sore or swollen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Have your gums receded (do teeth look longer)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Are your teeth loose?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you smoke or use tobacco products? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you drink excessively? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you have a persistent sore throat or ear pain?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ M Do you have unexplained numbness or pain in the face/neck/mouth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you have a sore or lesion on the lips or mouth that has persisted for 2 weeks or more? . . . . . . . . . . . . . . yes______ no______ Do you have chronic hoarseness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you have difficulty chewing, swallowing, or moving the jaw or tongue?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ E PL Do you have a lump or thickening in the cheek?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you snore or have you been told in the past you snore? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you regularly have excessive daytime sleepiness?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Have you been diagnosed with sleep apnea? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you have a heart condition? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Is there a history of heart disease in your immediate family? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you have a family history of diabetes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you have high cholesterol? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ Do you have any other health conditions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes______ no______ FOR OFFICE USE ONLY Record Blood Pressure ________________________ Item Code (125-0107) Total Health Brochure 082611:Layout 1 9/16/11 2:34 PM Page 1 Ideal Oral Health Care SA Daily brushing and flossing will help keep calculus formation to a minimum, but it won't completely prevent it. A professional dental cleaning at least twice a year is necessary to remove calculus from places your toothbrush and floss may have missed. Studies demonstrate that including flossing as part of your oral care routine can actually help Ask us reduce the amount of about a regular periodontal disease-causing bacteria found in the mouth, cleaning schedule designed for therefore contributing to your needs. healthy teeth and gums. Oral Health Care During Pregnancy Maintaining good oral health may be the best way to stay healthy and prevent disease. Talk to the Dentist today about any questions or health concerns you may have. For more information on Oral Systemic Health, please visit www.aaosh.org Your Mouth Is a Window Into the Health of the Rest of Your Body E PL M Pregnant women are at a higher risk of periodontal disease due to hormone fluctuations. Because periodontal disease in pregnant women has been linked to preterm, low birth-weight babies, it is essential that you maintain optimal If you are oral health care during pregnant or pregnancy. considering becoming pregnant, ask us about your periodontal health so you can ensure a happy, healthy pregnancy. Our dental office is dedicated to your overall health. To learn more about how Henry Schein contributes to improving health around the world, visit www.henryschein.com/hscares 11DF5576 Item Code (125-0108) Total Health Brochure 082611:Layout 1 9/16/11 2:34 PM Page 2 Oral Cancer Heart Disease Your mouth is a window into the health of the rest of your body. It can show signs of systemic disease or infection before they are visible elsewhere. We are trained to recognize these signs and administer testing that can identify disease or potential areas of concern. Regular dental visits will not only help you maintain healthy teeth and gums, but may help you prevent serious health conditions and maintain optimal overall well being. Thirty-six thousand new cases of oral cancer are diagnosed each year. Although we perform a We may use visual examination for oral cancer, an oral cancer occasionally there are lesions in the screening device to mouth that are not visible to the check for abnormal eye. Between visits to the dentist, perform self-checks and immediately tissue or use saliva testing to report any sores or lesions that do determine your oral not heal within 14 days to your cancer risk level. dentist. Early detection of oral cancer saves lives. Heart disease is the leading killer of men and women in the United States. Researchers have found that people with periodontal disease are almost twice as likely to suffer from coronary artery disease as those If you without periodontal disease. If smoke, and are you have periodontal disease diagnosed with combined with other risk factors periodontal disease, for heart disease, we may your risk of recommend you seek a medical developing heart evaluation. Periodontal disease disease is greatly can also aggravate existing heart increased. Talk to conditions, so it is essential to us today about get prompt treatment for quitting . periodontal disease. SA Total Health: Beyond the Mouth Oral Health Affects Total Health Periodontal Disease Oral Cancer and HPV HPV is a common, sexually transmitted virus that has infected more than 20 million people in the United States, with approximately 6 million new cases each year. Many do not realize they are infected, since HPV often has no signs or symptoms. At least one strain of HPV is now linked to the development of oral cancer. If you are sexually active, we may recommend a saliva test to check for HPV. This will help determine your risk level for oral cancer. M If you show When gums become infected and signs of periodontal inflamed from periodontal disease, disease, we may bacteria in plaque can spread and prescribe further grow below the gum line. The testing to rule out bacteria can then enter into the associated blood stream and travel to major conditions. organs and begin new infections. Ongoing research suggests that periodontal disease may be linked to heart disease, osteoporosis, and diabetes. Sleep Disorders From fifty to seventy million Americans suffer from chronic sleep disorders like habitual snoring and sleep apnea. Although snoring can be harmless, it can also be a sign of sleep apnea, which occurs when the tongue falls back into the throat during sleep and blocks the airway. People suffering from sleep apnea can stop breathing for 10 to If you have 30 seconds or longer, hundreds of signs of a sleep times a night. Untreated, sleep disorder, we may apnea can contribute to excessive recommend an daytime sleepiness as well as an at-home sleep test. increased risk for high blood We can help you pressure, heart attack, stroke, improve your quality diabetes, obesity, and driving of sleep. accidents. Today we know that diabetes and periodontal disease are closely linked. Treating and managing one can help improve the condition of the other. Although diabetics have a high risk of developing periodontal disease, improving the periodontal condition can If you have help improve management periodontal disease of the diabetes. combined with other risk factors for diabetes, we may recommend you seek a medical evaluation and receive immediate periodontal treatment. E PL Seventy-eight percent of the adult population has some form of periodontal disease. Periodontal disease is a serious inflammatory condition, caused by a bacterial infection, that leads to destruction of the We may attachment fibers and recommend saliva supporting bone that testing to hold your teeth in your determine your mouth. When fibers are genetic risk and destroyed, the gums current level of separate from the teeth, periodontal forming pockets that disease. become infected. As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed. When neglected, teeth can become loose and fall out. Although good oral care can help prevent periodontal disease, research shows that up to 30% of the population may be genetically susceptible to the disease. Despite oral care habits, these people may be six times more likely to develop periodontal disease. Diabetes Total Health Paitient Guide_Layout 1 1/16/14 2:21 PM Page 1 Patient Guide Screening Options Periodontal disease is a serious inflammatory condition, caused by a bacterial infection. As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed. Teeth can become loose and fall out. Although good oral care can help prevent periodontal disease, research shows that up to 30% of the population may be genetically susceptible to the disease. Despite oral care habits, these people may be six times more likely to develop periodontal disease. We may recommend saliva testing to determine your genetic risk and current level of periodontal disease. Periodontal Evaluation Saliva Testing SA Periodontal Disease Screening Options Although we perform a visual examination for oral cancer, occasionally there are lesions in the mouth that are not visible to the eye. We may use an oral cancer screening device to check for abnormal tissue. At least one strain of HPV is now linked to the development of oral cancer. HPV is a common, sexually transmitted virus that has infected more than 20 million people in the United States. Many do not realize they are infected, since HPV often has no signs or symptoms. We may recommend a saliva test to check for HPV and determine your risk level for oral cancer. Treatment Options Oral Cancer Screening Referral to a Physician Screening Options Epworth Sleepiness Scale www.aadsm.org/selftest.aspx Home Testing or Sleep Clinic Treatment Options Referral to a Physician Oral Appliance Continuous Positive Airway Pressure (CPAP) Therapy Surgery PL Heart Disease Oral Cancer Screening Saliva Testing Biopsy M While snoring can be harmless, it can also be a sign of sleep apnea, which occurs when the tongue falls back into the throat during sleep, blocking the airway. Untreated, sleep apnea can contribute to excessive daytime sleepiness as well as an increased risk for high blood pressure, heart attack, stroke, diabetes, obesity, and driving accidents. If you have signs of a sleep disorder, we may recommend an at-home sleep test. Scaling and Root Planing Periodontal Surgery Referral to a Periodontist Periodontal Disease Normal Oral Cancer Sleep Disorders Treatment Options Apnea Incident Normal Breathing Screening Options Diabetes Today, we know that diabetes and periodontal disease are closely linked. Treating and managing one can help improve the condition of the other. Although diabetics have a high risk of developing periodontal disease, improving the periodontal condition can help improve management of the diabetes. If you have periodontal disease combined with other risk factors for diabetes, we may recommend you seek a medical evaluation and receive immediate periodontal treatment. Periodontal Evaluation Heart Disease Risk Factors Review Treatment Options Normal Blood Flow Referral to a Physician Treatment of Periodontal Disease Smoking Cessation Program E Researchers have found that people with periodontal disease are almost twice as likely to suffer from coronary artery disease as those without periodontal disease. If you have periodontal disease combined with other risk factors for heart disease, we may recommend you seek a medical evaluation. Periodontal disease can also aggravate existing heart conditions, so it is essential to get prompt treatment for periodontal disease. If you smoke and are diagnosed with periodontal disease, your risk of developing heart disease is greatly increased – talk to us about quitting today. Estimated percentage of people aged 20 years or older with diagnosed and undiagnosed diabetes, by age group, United States, 2005–2008 Screening Options Periodontal Evaluation Diabetes Risk Test diabetes.org/risktest Treatment Options Referral to a Physician Treatment of Periodontal Disease For more information on Oral Systemic Health, please visit www.aaosh.org Item Code (125-0110)