Dental Questionnaire
for people affected with Multiple Osteochondromas (MO) and their families:
Please click and fill in the answers to all questions that apply in your case.
1.Date of birth
Year
Month
Day
Female
Male
Please answer next question if the respondent is under the age of 21 years old.
.Have you started puberty?
Yes
No
2. Do you have a family history of MO on your:
Father side?
Yes
Mother side?
Yes
No
No
3. Do you have any brothers or sisters who have been diagnosed with MO? If yes please fill in answer.
Yes
4. Were you diagnosed with MO or any other term used for this disease?
No
5. Have you been genetically tested in respect to MO?
Yes
No
If you have been genetically tested in respect to your MO, please click the answer that disribes you situation:
Yes
NO mutation was found?
No
A mutation in the
EXT1
gene was found
Yes
No
A mutation in the
EXT2
gene was found
Yes
No
I do not know the results of my genetic test.
Yes
No
6. If your mutation was found and you know detail about its type and location please give details (this information would be
given in the genetic testing report).
7. How do you consider yourself affected by MO?
Severely affected
Moderately affected
Not affected
No
8. Have you been diagnosed with any other chronic diseases or disorders ?
Yes
If yes please give more details.
9. Do you have any osteochondromas/exostoses/bony bumps in your jaws/mouth?
Upper jaw
Yes
No
If yes please give more details.
Yes
No
Lower jaw
If yes please give more details.
10. How often do you see a dentist?
11. Are your dental visits covered by insurance?
Yes
No
12. How many natural teeth do you have at present?
You can refer to picture above.
Upper jaw #
Lower jaw #
13. How many sound and untreated natural teeth do you have? (meaning no fillings or dental work or needed to be done now
on these teeth.)
Upper jaw #
Lower jaw #
14. Have you had any teeth removed?
Upper jaw #
Lower jaw #
If you had teeth removed, how many for what reason?
15. Do you have malformed or displaced teeth?
Yes
No
a.) Abnormal shape? (e.g. extra/missing, buckles, fused)
Yes
No
Details
Yes
b.) Out of line?
No
Details
c.) Other (please indicate)
Yes
16. Did your dentist ever refer to "abnormal enamel"?
No
17. How often do you experience toothache?
Never
Sometimes
Often
18. Do you have bleeding gingival (gums)?
Yes
No
19. Have you been told by your dentist you have Gingivitis?
No
Yes
20. Any other dental issues?
21. Any other comments:
If possible please send copies of photos and dental x-rays to Sarah Ziegler
Email
SarahZiegler@MHEResearchFoundation.org
or
Postal mail to attention Sarah Ziegler
149-34 16th Road
Whitestone, NY 11357
Respondents name:
Name of parent or guardian if this questionnaire is being submitted for a minor:
Email address:
Your home mailing address:
Your phone number
and or cell phone number:
I understand all personal identifiers/contact information will be removed and coded in order to keep my
anonymity/confidentiality before responses are sent to the Leiden University Medical Center for analyses.
Yes
I understand my personal identifiers/contact information will remain solely with the MHE Research Foundations
National MHE Research Registry
.
I understand my personal identifiers/contact information will not for any reason
be given/transferred without my written consent.
Yes
May Sarah Zielger contact you on behalf of the Leiden University Medical Center with additional questions?
Yes
No