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Step by Step to Good Oral Health

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On the following pages are a personal oral hygiene evaluation and program checklist. Part one will help to evaluate the level of ability the person with special needs has in maintaining his or her oral hygiene. Part two will help to develop a regular and realistic oral care program.

Take this form to your dentist or dental hygienist. He or She will complete it with you and talk with you about how best to help the person with special needs take care of his or her oral health.

This form is provided for printing purposes, it has no accessibility features.

Printable form

Patient Skills Evaluation Checklist PATIENT: _________________________________ DATE: ____________________________________ CAREGIVER: ______________________________
1. Classification of Cleaning Skills (please check one):
	Patient requires significant assistance
	Patient has some dexterity but insufficient cleaning techniques
	Patient can effectively brush with little assistance
	Patient requires virtually no assistance
2. Current Patient Brushing Method (please check one):
	Scrub Brush		Bass		Vibration
	Circular		Roll		Electric
3. Toothpaste Usage
Patient is using toothpaste			Yes		No
If yes, type of toothpaste used (e.g. tartar control) __________________________________________
4. Rinse (please check one):
	Patient rinses with chlorhexidine
	Patient rinses with fluoride (please specify) _________________
	Patient rinses with alternate rinse (please specify) ____________
	Patient unable to rinse; caregiver uses swab technique with chlorhexidine
	Patient is unable to rinse; caregiver uses swab technique with alternate rinse (please specify): ________________________________________________
5. Floss (please check one):
	Patient is able to floss
	Patient is able to floss with finger holder
	Patient is unable to floss; caregiver assistance needed
	Patient is unable to floss; no flossing technique currently used
6. Fluoride
	Liquid		Gel

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Program Development Checklist
Regimen	Patient	Caregiver
Toothbrushing
Monitor Activity
Toothbrush Modification
Electric Toothbrush
Toothpaste
Water
Fluoride Rinse
Fluoride Gel
Chlorhexidine Rinse
Chlorhexidine Brushing
Chlorhexidine Swab
Red Dye Program
Saliva Substitute
Floss
Reinforcers (e.g. food, TV, book)
Support
Arm
Head
Hand
Verbal Instructions
Position of Caregiver
Other:
Additional Comments/Instructions:

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