Lampiran 3.

Form WHO

ANNEXURE B
WHO ORAL HEALTH ASSESSMENT FORM (2004)
(Designed by WHO Oral Health Programme, Geneva) Identification
Country Year Month Day number Original Examiner duplicate

(1)

(4)

(5)

(6) (7)

(10) (11)

(14)

(15)

(16)

GENERAL INFORMATION
Age in years (17)

Name:____________ _ _ _ _ _ _ _ _ _ _ _ ____________________ OTHER DATA (Specify and provide codes) Geographic location (22) (23) (Box 22, code of participating centre, Box 23, code of selected group 1234 for Urban/5678 for Rural) (25)

(18)

(Box 17 & 18, Completed age in years

Sex (M = 1, F = 2) Ethnic group

(19)

(26)

Location type:
(20) 1=Urban 3 = Rural (24)

(Box 20, Not to be recorded) Occupation (21) (27)

0 = Non skilled worker (Peon, Labourer, Farmer), 1 = Skilled worker (Carpenter, Masion), 2 = Professional, 3 = Businessman, 4 = Housewife, 5 = School going child, 6 = Non school going child, 7 = , 8 = Non-employed, 9 = No available information

EXTRA-ORAL EXAMINATION
0 = Normal ekstra-oral appearance 1 = Ulceration, sores, erosions, fissures (head, neck, limbs) 2 = Ulceration, sores, erosions, fissures (nose, cheeks, chin) 3 = Ulceration, sores, erosions, fissures (commissures) (28) 4 = Ulceration, sores, erosions, fissures (vermillion border) 5 = Cancrum oris 6 = Abnormalities of upper and lower lips 7 = Enlarged lymph nodes (head, neck) 8 = Other swellings of face and jaws 9 = Not recorded

DENTURE WEARING
Upper (29) 0 = No denture 1 = Partial denture 2 = Full denture Lower (30)

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DENTITION STATUS
18 17 16 55 54 53 52 51 61 62 63 64 65 26 26 27 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Status (31) 48 47 46 85 84 83 82 81 71 72 73 74 75 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Status (47) (62) (46)

STATUS
Permanent teeth
0 1 2 3 4 5 6 7 7 8 9 T = Sound = Decayed = Filled and decayed = Filled, no decay = Missing due caries = Missing, any other reason = Sealant, varnish = Bridge abutment = or special crown = Unerupted tooth = Excluded tooth = Trauma (Fracture)

Primary teeth
A B C D E F G T

PERIODONTAL STATUS (CPI modified)

18 17 16 55 54 53 52 51 61 62 63 64 65 26 27 28 18 17 16 15 14 13 12 21 21 22 23 24 25 26 27 28 Bleeding Pocket (63) (79) 18 17 16 85 84 83 82 81 71 72 73 74 75 26 27 28 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Bleeding Pocket (95) (111) (110) (126) (78) (94)

Gingival bleeding scores: (0) Absence of condition (1) Presence of condition (9) Tooth excluded (X) Tooth not present

Pocket scores: (0) Absence of condition (1) Pocket 4-5 mm (2) Pocket 6 mm or more (9) Tooth excluded (X) Tooth not present
17/16 11 26/27

LOSS OF ATTACHMENT
0 = 0-3 mm 1 = 4-5 mm (cementoenamel junction (CEJ) within black band) 2 = 6-8 mm (CEJ between upper limit of black band and 8.5 mm ring) 3 = 9-11 mm (CEJ between 8.5 mm and 11.5 mm ring) 4 = 12 mm or more (CEJ beyond 11.5 mm ring) X= Excluded sextant 9 = Not recorded * Not recorded under 15 years of age
(127) (130)

(129) (132)
47/46 31 36/37

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ORAL MUCOSA
(133) (134) CONDITION 0 = No abnormal condition (135) (136) 1 = Malignant tumour (oral cancer) (137) (138) 2 = Leukoplakia 3 = Lichen planus 4 = Ulceration (apthous, herpetic, 4 = traumatic) 5 = Acute necrotizing gingivitis 6 = Candidiasis 7 = Abscess 8 = Other condition (specify if possible) .............................. 9 = Not recorded

LOCATION 0 = Vermillion border 1 = Commissures 2 = Lips 3 = Sulci 4 = Buccal mucosa 5 = Floor of mouth 6 = Tongue 7 = Hard and/or soft palate 8 = Alveolar ridges/gingiva 9 = Not recorded

FLUOROSIS
(139) 0 1 2 3 4 5 8 9 = Normal = Questionable = Very mild = Mild = Moderate = Severe = Excluded = Not recorded

NEED FOR IMMEDIATE CARE

Life threatening condition Jaws fracture Pain or infection Referral to care 0 = Absent 1 = Present/referral
(140) (141) (142) (143)

165