Version June 2024
| Resident's name | Date | |||
| Examiner's name | TOTAL SCORE | |||
| Category | Measurement | 0 | 1 | 2 |
| Lymph nodes | Observe and feel nodes | No enlargement | Enlarged, not tender | Enlarged and tender* |
| Lips | Observe, feel tissue, and ask resident, family, or staff (eg, primary caregiver) | Smooth, pink, moist | Dry, chapped, or red at corners* | White or red patch, bleeding or ulcer for 2 weeks* |
| Tongue | Observe, feel tissue, and ask resident, family, or staff (eg, primary caregiver) | Normal roughness, pink, and moist | Coated, smooth, patchy, severely fissured or some redness | Red, smooth, white, or red patch; ulcer for 2 weeks* |
| Tissue inside cheek, floor and roof of mouth | Observe, feel tissue, and ask resident, family, or staff (eg, primary caregiver) | Pink and moist | Dry, shiny, rough, red, or swollen* | White or red patch, bleeding, hardness; ulcer for 2 weeks* |
| Gums between teeth and/or under artificial teeth | Gently press gums with tip of tongue blade | Pink, small indentations; firm, smooth, and pink under artificial teeth | Redness at border around 1 to 6 teeth; 1 red area or sore spot under artificial teeth* | Swollen or bleeding gums, redness at border around seven or more teeth, loose teeth; generalized redness or sores under artificial teeth* |
| Saliva (effect on tissue) | Touch tongue blade to center of tongue and floor of mouth | Tissues moist, saliva free flowing and watery | Tissues dry and sticky | Tissues parched and red, no saliva* |
| Condition of natural teeth | Observe and count number of decayed or broken teeth | No decayed or broken teeth/roots | 1 to 3 decayed or broken teeth/roots* | 4 or more decayed or broken teeth/roots; fewer than 4 teeth in either jaw* |
| Condition of artificial teeth | Observe and ask patient, family, or staff (eg, primary caregiver) | Unbroken teeth, worn most of the time | 1 broken/missing tooth, or worn for eating or cosmetics only | More than 1 broken or missing tooth, or either denture missing or never worn* |
| Pairs of teeth in chewing position (natural or artificial) | Observe and count pairs of teeth in chewing position | 12 or more pairs of teeth in chewing position | 8 to 11 pairs of teeth in chewing position | 0 to 7 pairs of teeth in chewing position* |
| Oral cleanliness | Observe appearance of teeth or dentures | Clean, no food particles/tartar in the mouth or on artificial teeth | Food particles/tartar in 1 or 2 places in the mouth or on artificial teeth | Food particles/tartar in most places in the mouth or on artificial teeth |
| Upper dentures labeled: Yes _____ No _____ None _____ | ||||
| Lower dentures labeled: Yes _____ No _____ None _____ | ||||
| Is your mouth comfortable? Yes _____ No _____ If no, please explain: | ||||
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| Additional comments:
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آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
