8/2/2019 Periodontal Risk 3

1/2

Name_______________________________________ Date____________

HEARTATTACK/STROKE

Untreated gum diseasecan increase your risk forheart attack and stroke.

TOBACCOUSE

Tobacco use is the mostsignificant risk factor for

gum disease.

Please check the box if you nowor have everused

Cigarette Cigar Pipe Chew SnuffIf yes, please list

Amount Used for how If you quit,per day many years list what year

_______ __________ __________Do any other members of your household use tobacco? Yes NoDo you have any other risk factors for heartdisease or stroke?

Family history of heart disease Tobacco use High cholesterol High blood pressureIf you have any of these other risk factors it is especiallyimportant for you to always keep your gums as healthy andinflammation free as possible to reduce your overall risk for heartattack and stroke.

MEDICATIONSA side effect of some

medications causeschanges in your gums.

Have you ever taken any of the following medications?

Dilantin anti-seizure medication. Calcium Channel Blocker blood pressure medication (suchas Procardia, Cardizem, Norvasc, Verapamil, etc.).

Cyclosporin immunosuppresant therapy.GENETIC

The tendencyfor gum diseaseto develop can be

inherited.

Has anyone on your side of the family had gum problems(e.g. your mother, father, or siblings)?

yes No

A chip offthe oldblock!

CONTAGIOUSThe bacteria whichcause gum disease

may be spread to aspouse or other membersin your household.

If one family member has periodontal disease, guidelinessuggest that all family members see a dental professional for aperiodontal disease screening.

Has everyone in your household been screened for thepresence of gum disease? Yes No

Artificial JointWhen you have

gum disease bacteria getsinto the bloodstream daily.These bacteria can lodgeon an artificial joint andcause a serious infection.

Do you have an artificial joint? Yes NoIf you have an artificial joint it is important for you to do whatever isnecessary to keep oral inflammation to a minimum over your lifespan.Doing so will reduce your risk for a serious joint infecdtion.

Assessment Questionnaire

The following stressful events can significantly reduce yourresistance to things like gum disease:Death of spouse Divorce/ separation Jail term PregnancyDeath in family Injury / illness Marriage RetirementLoss of job Change in financesHave you recently been dealing with any of these major

stressors? Yes No

STRESSMajor stressors

have a very definiteadverse affect on yourimmune system.

Periodontal Risk

8/2/2019 Periodontal Risk 3

2/2

Alzheimers DiseaseResearchers are now investigating

the role of gumdisease in thedevelopment ofAlzheimers Disease.

Rheumatoid ArthritisThe causes of gum disease and

RA may be related. Onedoesnt cause the other,but when one is presentthe other is more likely tobe going on. If your gums

are inflamed you may be atincreased risk for developing RA.

DiabetesDiabetics are moreprone to gumdisease. If leftuntreated, gumdisease makes it

harder for diabetics to control theirblood sugar. When gum disease iseliminated, diabetics improve theirblood sugar control and makediabetic complications less likely.

Any family history of diabetes? yes noHave you had any of these warning signs of diabetes?

frequent urination excessive thirst excessive hunger weakness and fatigue slow healing of cuts unexplained weight lossIF YOU HAVE DIABETES,How is your diabetes control? good fair poorWhen was your last A1c_________What score?________Who is your physician for diabetes?_________________

Have you ever been diagnosed with Rheumatoid Arthritis?yes noIf you have rheumatoid arthritis, emerging research suggeststhat eliminating any gum disease and then keeping it at baycan lessen the crippling effects of arthritis.

Are you overweight? We can calculate your weight statusby using Body Mass Index (BMI) and waist size.

BM I= (703 x weight)/(height)218.4 or below Underweight18.5 to 24.9 Healthy weight25.0 to 29.9 Overweight>30.0 Obese

What is your current weight__________________

What is your Your current height______________

What is your current waist size_______________

Do you eat a balanced diet? yes no

Do you have a family history of Alzheimers Disease?

yes no

Obesity Being overweight hasbeen linked with anincreased risk forcardiovasculardisease, diabetes

and gum disease. If you areoverweight you should be testedfor gum disease, diabetes and

cardiovascular disease.

FEMALESTell us if you are or are planning to become pregnant. Gum diseasecan make it up to eight times more likely that you will have a pre-term, low birth weight baby. You can greatly reduce the likelihood ofhaving an adverse pregnancy outcome by finding out if you havegum disease and then doing whatever is necessary to eliminate itbefore you get pregnant. It is also important to make sure your

gums are inflammation free while you are pregnant.

Do you have osteoporosis? Yes No Dontknow

These following are risk factors for osteoporosis:Post-menopausal Family history of osteoporosis Earlymenopause Rheumatoid Arthritis Inadequate exerciseSmoking

Do you any risk factors for osteoporosis?Yes NoHave you ever been tested? Yes No

Healthy waist sizeMale less than 40Female less than 35

Special Concerns for Females