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Table 1 The domains and item questions of the questionnaire (translated in English)

From: Assessment of oral self-care in patients with periodontitis: a pilot study in a dental school clinic in Japan

Domains Items
Oral hygiene 1. Frequency of toothbrushing
  2. Use of toothpaste
  3. Approximal cleaning
  4. Use of mouthwash or other products
Dietary habit 1. Frequency of meal
  2. Self evaluation of diet
  3. Frequency of between-meal snacks
  4. Types of snacks
Perception of oral condition 1. How often do you check your teeth or mouth inside in a mirror?
  2. How would you rate your desire to keep your teeth?
  3. What are your hopes for your oral health?
  4. How much are you willing to do to improve your oral health?
  5. What actions you are likely to take to improve your oral health?
  6. Have you been maintaining regular dental check-ups?
  7. How much do you follow your dentist's or dental hygienist's advice on oral hygiene care?
  8. How important is the prevention of cavities or gum diseases for you?
  9. Would you like your dentist or dental hygienist to recommend oral care products?
  10. Are you willing to take new challenges and/or change your daily routine?
  11. How do you perceive consequences of your actions on oral health?