home Audience 4 Templates for filling out dental records for periodontitis. Algorithm for preparing a “medical record for a dental patient.” What is a dental patient's medical record?

Templates for filling out dental records for periodontitis. Algorithm for preparing a “medical record for a dental patient.” What is a dental patient's medical record?

A dental patient's medical record is a document used to identify the patient. The medical record describes the characteristics of the condition and changes in its health.

All medical record data is filled out by a doctor and confirmed by instrumental, laboratory and hardware research data. In addition, the medical record reflects all the features and stages of treatment.

For each dental patient, several documents are drawn up, which include informed voluntary consent for dental treatment, consent to the processing of personal data and a medical record of the dental patient.

We were told about the rules for their registration at the RaTiKa dental clinic (Ekaterinburg).

Medical record of a dental patient

Back on October 4, 1980, by Order of the USSR Ministry of Health No. 1030, form 043/u was approved, which was intended specifically for maintaining records of dental patients.

Dentists were obliged to strictly adhere to this form, but already in 1988 the above order was canceled. Since then, no law has been issued that would order dentists to use a specific form of medical record. However, on November 30, 2009, the Ministry of Health and Social Development of the Russian Federation issued a letter in which it recommended that doctors use the old forms to keep records of their activities (for dentists - 043/u).

Current legislation recommends (but does not oblige) the use of form 043/у for medical records of dental patients. However, it is most convenient to maintain patient records in the appropriate dental management programs.

Most clinics do use this form, but often transform it slightly to a more convenient format, for example, instead of A5 they print in A4 format or make other minor changes.

A dental patient's medical record is completed upon the patient's first visit to the dental clinic. Personal information (full name, gender, age, etc.) is filled out by a nurse or dental administrator, and the rest of the card is filled out exclusively by the attending physician.

Rules for drawing up a medical card for a dental patient by a doctor

The card contains information about the patient’s diagnosis and complaints.
The diagnosis is entered into the chart after the examination.
It is possible to clarify the diagnosis or completely change it. When making amendments, the date must be indicated.
It is important to note the presence of concomitant diseases of the patient or those significant for dental procedures, diseases that he has already suffered.
It is necessary to describe how the current disease develops, include data obtained during an objective study, information about the bite, the condition of the mucous membrane, oral cavity, gums, alveolar processes, and palate.
X-rays and laboratory tests must also be included in the dental patient’s chart.

Each of them should write down their treatment steps on a separate insert and then place them on the chart.

Rules for storing medical records

The medical card must be kept at all times; it is not given to the patient at home. But we recommend that you give the patient a special form that indicates the date of the next visit. You can develop and release it yourself or use one offered by partner companies, for example, a toothpaste manufacturer.
Considered a legal document, the card must be stored for 5 years from the day when the patient last visited the dentist and a corresponding entry was made about this in the card. The document is then transferred to the archive.
The content of medical records should prevent the possibility of violation of confidentiality and illegal access to them, so it is best to keep them under lock and key.

Informed voluntary consent to dental treatment

Dental services belong to the “List of certain types of medical interventions to which citizens give informed voluntary consent when choosing a doctor and medical organization to receive primary health care,” which was approved on April 23, 2012 by the Ministry of Health and Social Development of the Russian Federation. By signing this document, the patient indicates that he is voluntarily undergoing dental treatment; the need for certain procedures, the plan of which is prescribed in his medical record, was explained in detail to him. The client demonstrates an understanding of possible outcomes, existing risks, and alternative treatment pathways. He knows about the possible accompanying effects of the planned treatment (pain, discomfort, swelling of the face, sensitivity to cold/heat, etc.). The patient also confirms his understanding that the treatment plan may change during the process.

The document can be signed by the patient himself or an authorized representative (if there is a document that confirms the right to represent his interests).

Consent to the processing of personal data

This document gives the organization the right to process the patient’s personal data (full name, date of birth, type of identification document, etc.) in accordance with existing legislation. If the patient is a minor, then consent to the processing of personal data is signed by parents or legal representatives.

All materials are provided by the RaTiKa dental clinic (Ekaterinburg). Text: Elizaveta Gertner

OKUD form code ___________

OKPO institution code ______

Medical documentation

Form No. 043/у

Approved by the USSR Ministry of Health

04.10.80 No. 1030

name of institution

MEDICAL CARD

dental patient

No. _____________ 19... ____________

Full Name ________________________________________________________

Gender (M., F.) ______________________ Age ___________________________________

Address _________________________________________________________________________

Profession _____________________________________________________________________

Diagnosis ________________________________________________________________________________

Complaints ______________________________________________________________________________

Previous and concomitant diseases _____________________________________________

_______________________________________________________________________________

Development of the present disease ________________________________________________

_______________________________________________________________________________

For the printing house!

when preparing a document

A5 format

Page 2 f. No. 043/у

Objective research data, external examination ______________________________

_______________________________________________________________________________

Examination of the oral cavity. Dental condition

Legend: none -

0, root - R, Caries - C,

Pulpitis - P, periodontitis - Pt,

sealed - P,

Periodontal disease - A, mobility - I, II

III (degree), crown - K,

art tooth - I

_______________________________________________________________________________

Bite __________________________________________________________________________

Condition of the oral mucosa, gums, alveolar processes and palate

_______________________________________________________________________________

X-ray and laboratory data ______________________________

_______________________________________________________________________________

Page 3 f. No. 043/у

date		Last name of the attending physician

Treatment results (epicrisis) ___________________________________________________

_______________________________________________________________________________

Instructions ___________________________________________________________________

_______________________________________________________________________________

Attending physician _______________ Head of department _____________________

Page 4 f. No. 043/у

Treatment _______________________________________________________________________

_______________________________________________________________________________

	History, status, diagnosis and treatment when dealing with recurrent diseases	Last name of the attending physician

Page 5 f. No. 043/у

Survey plan	Treatment plan	Consultations

etc. to the end of the page

Recommendations for students on filling out a medical record of a dental patient with defects of hard dental tissues

AT THE DEPARTMENT OF ORTHOPEDIC DENTISTRY

Medical record of a dental patient

The main document for recording the work of a dentist of any specialty is the medical record of a dental patient, form 043-u, approved by order of the USSR Ministry of Health No. 1030 dated October 4, 1980.

A medical card (outpatient card or medical history) is a mandatory document for a medical outpatient appointment that performs the following functions:

is a plan for a thorough examination of the patient;
records data from anamnesis, clinical and paraclinical examination methods of the patient, reflecting the condition of the organs and tissues of his oral cavity;
records the plan and stages of treatment, changes in the patient’s condition;
makes it possible to compare the results of surveys conducted at different times;
provides data for scientific research;
is a legal document considered in various conflict situations, including in courts.

A medical record of an approved form is issued, as a rule, by printing. Currently, clinics practice the use of a formalized computer version of the outpatient card, but with the condition of mandatory duplication on paper.

Medical card (registration form 043–у) includes:

passport part, which is filled out at the reception desk during the patient’s initial visit to the clinic;
medical unit, which is filled out directly by the doctor and includes:

- anamnestic information (complaints, medical history, previous and concomitant diseases, life history, allergy history);

- dental status (external examination, examination of the oral cavity);

- data from additional studies (for example, electroodontometry, radiography);

- diagnosis ( basic dental, reflecting morphological and functional disorders of the dental system; concomitant dental; concomitant somatic);

- treatment plan, including, if necessary, preparatory measures (sanitation and special) and the actual methods of orthopedic treatment;

- treatment diary.

Writing a medical history of patients in an orthopedic dentistry clinic should be based on consistent, sufficiently detailed, competent and accurate completion of all columns of the outpatient chart of a dental patient, so that anyone reading it can understand the content of the records.

Features of writing a patient's medical history

with defects of hard dental tissues

^ RATIONALE FOR THE DIAGNOSIS
1. SURVEY

In the column "Complaints" medical records record data from the patient's words. The nature of the patient’s complaints is determined in most cases by whether the tooth with hard tissue pathology belongs to a certain functional group:

in case of defects in the hard tissues of the anterior group of teeth - problems of an aesthetic nature caused by congenital or acquired defects in the surface and color of dental tissues, changes in their shape or position in the dentition, destruction or complete absence of the crown part, etc.;
when the crowns of the chewing group of teeth are destroyed, chewing function is impaired;
with significant destruction of a large number of teeth - changes in appearance (changes in facial proportions), pain in the temporomandibular joint;
in some cases - increased sensitivity of teeth (for example, with increased abrasion of hard dental tissues, with wedge-shaped defects).

Count « Development of the present disease" The time of appearance of the first signs of the disease, its causes, dynamics of development, previous treatment and its results are indicated.

Count "Previous and concomitant diseases" - data is entered on general somatic pathology: diseases of the cardiovascular system, gastrointestinal tract, endocrine pathology, past infectious diseases, etc. The listed pathological conditions can influence the choice of materials for the manufacture of prostheses, the timing of the start of prosthetics, the stages of planned treatment, selection of anesthetic agents during dental preparation. Thus, to administer anesthesia to patients with pathologies of the cardiovascular system, the anesthetic should not contain adrenaline.

Count "Allergological history" The patient is asked whether there have been any allergic reactions to medications, household chemicals, food products, etc., whether anesthesia has been used previously, and whether any complications have been noted after it.

To diagnose the pathological condition of the dental system, a thorough study must be carried out patient's dental status followed by a detailed description of it in the medical record.

In concept "dental status" includes data from the patient’s external examination and examination of his oral cavity.

When describing the results of an external examination, special attention should be paid to:

signs of changes in proportions - a decrease in the height of the lower part of the face, which may be due to significant destruction of a large number of chewing teeth, increased abrasion of hard dental tissues;
the nature of the movements of the lower jaw;
the nature of the movements of the heads of the temporomandibular joints (as determined by palpation).

Example: ^ The face is symmetrical and proportional. Full mouth opening. Movements of the lower jaw are free and uniform.

When describing the results of an examination of the patient’s oral cavity, fill in dental formula, which is a two-digit system in which the quadrants (segments) of the jaws and each tooth of the jaw are numbered alternately (from right to left on the upper jaw and from left to right on the lower jaw). Teeth are numbered from the midline. The first number indicates a quadrant (segment) of the jaw, the second number indicates the corresponding tooth.

^ Example:

P s R ShtZ P K K

18 17 16 15 14 13 12 11 ! 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 ! 31 32 33 34 35 36 37 38

S P p K K

In the dental formula, in accordance with the symbols, all teeth are noted ( ^P– sealed; WITH– with carious cavities, R – with significantly or completely destroyed coronal part); degree of tooth mobility ( 1, P, Sh, 1U), teeth with orthopedic structures ( TO– artificial crowns, ShtZ– pin tooth) etc.

Under the dental formula, additional data is recorded regarding the teeth that are subject to restoration by orthopedic methods: the degree of destruction of the coronal part, the presence of fillings and their condition, changes in color and shape, position in the dentition and relative to the occlusal surface of the dentition, exposure of the neck, stability (or degree of mobility) , results of probing and percussion. The condition of the marginal periodontium is described separately, in particular, changes in the gingival margin (inflammation, recession), the presence of a gingival pocket, its depth, and the ratio of the extra- and intra-alveolar parts of the tooth.

Example:

16 – there is a filling on the chewing surface, the marginal seal is broken, the neck of the tooth is exposed, the tooth is stable, percussion is painless.

14 – on the medial surface there is a small carious cavity; probing the cavity is painless.

13 – there is a complete absence of the crown part of the tooth, the root protrudes above the gum level by 0.5-1.0 mm, the root walls are of sufficient thickness, dense, without pigmentation, the root is stable, percussion is painless, the marginal gum without signs of inflammation, tightly covers the neck of the tooth.

11 – artificial metal-plastic crown, plastic lining is discolored, hyperemia of the marginal edge of the gums is noted.

21 – the coronal part is discolored, the medial corner of the incisal edge is chipped, the tooth is stable, located in the dental arch, percussion is painless.

26, 27, 37, 36 – artificial all-metal crowns in satisfactory condition, tightly covering the necks of the teeth, marginal gums without signs of inflammation.

31, 32, 41, 42 – dental plaque, slight hyperemia of the gingival margin.

45 – the filling on the occlusal surface is of satisfactory quality, the marginal fit of the filling is not broken, percussion is painless.

46 – on the occlusal surface there is a large filling, changed in color; probing reveals a violation of the marginal seal, a chip of the medial lingual tubercle, the tooth is stable, percussion is painless.

In the column "Bite" record data on the nature of the relationship of the dentition in the position of central occlusion, the depth of overlap in the anterior section and the identified deformation of the occlusal surface of the dentition.

Example:The bite is orthognathic. The crowns of the upper front teeth overlap the lower teeth by more than 1/3. Violation of the surface of the closure of the dentition due to the advancement of the 46th tooth relative to the occlusal surface by 1.5 mm (or by ¼ of the height of the crown). There is hypertrophy of the alveolar process in the area of 46, exposure of the neck of the tooth.

In the column " Data from additional research methods » the results of x-ray examinations are recorded with a detailed description of x-rays of each tooth subject to orthopedic treatment. When “reading” x-rays, the condition of the tooth shadow is assessed and described according to the following scheme:

condition of the crown - presence of a carious cavity, filling, relationship between the bottom of the carious cavity and the tooth cavity;
characteristics of the tooth cavity - the presence of a shadow of filling material, instruments, denticles;
condition of roots: number, shape, size, contours;
characteristics of root canals: width, direction, degree and quality of filling;
assessment of the periodontal gap: uniformity, width;
state of the compact plate of the socket: preserved, destroyed, thinned, thickened;
the condition of the periapical tissues, analysis of the pathological shadow, determination of its location, shape, size and nature of the contour;
assessment of surrounding tissues: condition of interdental septa - height, condition of the compact endplate.

^ Example:

On intraoral x-rays of satisfactory quality:

16 – a change in the position of the tooth relative to adjacent ones is determined (advancement by 1.5 mm in relation to the occlusal surface), in the coronal part of the tooth there is an intense shadow of the filling material, close to the tooth cavity, the marginal fit of the filling is broken, atrophy of the interdental septa up to 1/3 of the length roots

13 – absence of a coronal part; in the root canal, along the entire length of the canal to the apex of the root, there is a uniform, intense shadow of the filling material. The periodontal gap is not widened, there are no changes in the periapical tissues.

11 – in the area of the coronal part, an intense shadow of the metal frame of the artificial crown is projected; in the root canal, up to ½ of its length, an intense shadow of a metal wire pin can be traced. In the apical third of the root canal, the shadow of the filling material is not visible. Uniform expansion of the periodontal fissure. In the area of the root apex there is a focus of rarefaction of bone tissue with unclear contours in the form of “tongues of flame”.

21 – chipping of the medial corner of the cutting edge of the coronal part; in the root canal there is an intense shadow of filling material with filling defects. No changes were detected in the periapical tissues.

46 – in the area of the tooth crown there is a shadow of the filling material, located close to the tooth cavity, the marginal fit of the filling is broken, the root canals are free of filling material. There are no changes in the periapical tissues.

32, 31, 41, 42 – no pathology of hard tissues was detected, interdental septa were reduced to 1/3 of the length of the roots, there was an absence of compact end plates, the apexes had a “scalloped” appearance.

The same column describes the data of electroodontodiagnosis and other examination methods (for example, the results of tomography of the temporomandibular joints in patients with signs of declining occlusion).

Based on the data of the clinical examination and the results of additional research methods, a diagnosis . Accordingly, the column "diagnosis" in the medical record is filled out only after a complete examination of the patient.

When making a diagnosis, it is necessary to highlight:

underlying disease of the dental system and complication of the underlying disease;
associated dental diseases;
common concomitant diseases.

The main diagnosis must be detailed, descriptive and correspond to the international classification of nosological forms of dental diseases based on ICD-10 C.

When formulating the main diagnosis, first of all, morphological changes in the dental system are distinguished, indicating the etiological factor (for example, partial defect of the coronal part of the 46th tooth of carious origin).

In some cases, the underlying disease (in the example given) partial defect of the crown part of the 46th tooth) may be accompanied by complications, in particular in the form of deformations of the occlusal surface of the dentition (change in the position of the 16th tooth - dentoalveolar lengthening of the 1st degree of P-a form in the area of the 16th tooth), which should also be reflected in the diagnosis.

In the given example morphological part of the main diagnosis is formulated as follows:

“Complete defect of the coronal part of the 13th tooth of carious origin (IROPD more than 0.8). Functional and aesthetic failure of the artificial crown of the 12th tooth. Partial defect with a change in the color of the hard tissues of the 21st tooth of traumatic origin. Partial defect of the coronal part of the 46th tooth of carious origin, complicated by deformation of the occlusal surface of the dentition of the upper jaw - dentoalveolar lengthening of the 1st degree of P-a form in the area of the 16th tooth."

The second component of the main diagnosis is functional part, characterizing dysfunction and movement of the lower jaw. For example, “Aesthetic insufficiency of the dentition of the upper jaw”, « Functional deficiency of the lower jaw dentition», "Blocking the movements of the lower jaw."

In the example given, the full formulation main diagnosis as follows:

“Complete defect of the coronal part of the 13th tooth of carious origin (IROPD more than 0.8). Functional and aesthetic failure of the artificial crown of the 12th tooth. Partial defect with a change in color of the hard tissues of the 21st tooth of traumatic origin. Partial defect of the coronal part of the 46th tooth of carious origin, complicated by deformation of the occlusal surface of the dentition of the upper jaw - - dentoalveolar lengthening of the 1st degree of P-a form in the area of the 16th tooth. Functional and aesthetic insufficiency of the dentition, blocking the movements of the lower jaw in anterior occlusion.”

IN concomitant dental diagnosis All identified dental pathologies are removed, the treatment of which will be handled by dental therapists, dental surgeons, orthodontists (for example, caries, chronic periodontitis, gingivitis, periodontitis, diseases of the oral mucosa, etc.).

Example: « ^ Deep incisal overlap. Chronic localized catarrhal gingivitis in the area of teeth 11, 32, 31, 41, 42. Dental caries 14, 47.”

IN concomitant somatic diagnosis somatic diseases of the cardiovascular, endocrine, nervous systems, respiratory organs, gastrointestinal tract, etc. are noted.

Depending on the formulation of the diagnosis, a treatment plan , which, in addition to the actual orthopedic treatment of a defect in the hard tissues of the tooth, may include preliminary preparation of the oral cavity for prosthetics. Preparation of the oral cavity for orthopedic treatment includes are common(rehabilitation) and special measures (therapeutic, surgical, orthopedic, orthodontic).

Sanitation measures are carried out if the accompanying dental diagnosis indicates the presence of teeth to be treated (caries, chronic periodontitis), diseases of periodontal tissues (dental deposits, gingivitis, periodontitis in the acute stage), diseases of the oral mucosa, etc.

Example: “The patient is sent for sanitation of the oral cavity before prosthetics: treatment of teeth 14, 17, removal of dental plaque, treatment of gingivitis. Professional oral hygiene is recommended.”

Special dental preparation It is performed according to prosthetic indications and is necessary for more effective orthopedic treatment and to eliminate the possibility of complications developing after treatment.

Before orthopedic treatment of defects in hard dental tissues, special therapeutic measures preparation of teeth, among which it should be noted:

refilling of root canals;
depulpation of teeth planned for orthopedic construction (for example, if radical preparation of teeth with a wide cavity is necessary, with tilting or vertical movement of teeth);
preparation of root canals for pin structures (unsealing of root canals).

The ultimate goal of orthopedic treatment of hard tissue defects is to restore:

anatomical shape of the tooth crown;
unity of the dentition;
lost functions and aesthetics.

In this regard, in the column "Treatment Plan" The designs of dentures with the help of which the goal of orthopedic treatment will be realized must be indicated.

^ Example:

“Restore the anatomical shape of the coronal part

tooth 16 – cast all-metal crown;

teeth 13, 11 – metal-ceramic crowns on cast cores

pin tabs;

tooth 21 – metal-ceramic crown;

tooth 46 – cast all-metal crown on a cast stump pin insert.

If it is necessary to carry out special preparation of a tooth for prosthetics, the planned activities should also be described in detail in the column "Treatment plan."

Example:

In order to eliminate deformation of the occlusal surface of the dentition of the upper jaw, it is recommended to depulpate the 16th tooth, followed by its grinding (shortening) and restoration of its shape with a cast all-metal crown.
Restore the anatomical shape of the crown of the 13th tooth with a cast stump pin and a metal-ceramic crown with preliminary preparation of the root canal for the cast stump pin (unsealing 2/3 of the length).
Restore the anatomical shape of the coronal part of the 11th tooth with a cast stump pin and metal-ceramic crown with preliminary revision, refilling and preparation of the root canal for the cast stump pin.
Restore the anatomical shape of the coronal part of the 21st tooth with a metal-ceramic crown with preliminary refilling of the root canal using a fiberglass pin.
Restore the anatomical shape of the crown of the 46th tooth with a cast stump pin insert and a cast all-metal crown with preliminary depulpation of the tooth and preparation of channels for the cast stump pin insert.

The patient should be informed by the doctor about all possible options for dental prosthetics and the most optimal method of treatment in a given clinical situation, about treatment planning (including the need to prepare the oral cavity for prosthetics for orthopedic indications). An appropriate entry should be made in the medical history (preferably by the patient himself and with his signature) with the following wording: “ I am familiar with the options for prosthetics and agree with the prosthetics plan (including the preparation plan for prosthetics).

In chapter "Diary » describes the clinical stages of orthopedic treatment, indicating the date of the patient’s appointment and the date of the next appointment. Here are examples of filling "Diary" depending on the design of the denture in the orthopedic treatment of defects in the hard tissues of teeth.

date	Diary	Last name of the attending physician
^ Orthopedic treatment using a stamped metal crown
27.02.09	Preparation of the 27th tooth for a stamped metal crown. Obtaining a working two-phase impression using silicone impression material (for example, Speedex) and an auxiliary impression from the lower jaw with alginate impression mass (for example, Cromopan). Turnout 03/01/09.	Signature
01.03.09	Fitting a metal stamped crown for 27 teeth. No comments. Turnout 03/02/09	Signature
02.03.09	Final fitting and fixation of a stamped metal crown for 27 teeth with phosphate cement (for example, Unicem). Recommendations are given.	Signature
^ Orthopedic treatment using a plastic crown
27.02.09	Preparation of 21 teeth for a plastic crown. Obtaining a working two-phase impression using silicone impression material (for example, Speedex Cromopan) from the lower jaw. Selecting the color of the plastic according to the Sinma plastic color scale (for example, color No. 14). Turnout 03/01/09	Signature
01.03.09	Fitting a plastic crown with correction of occlusal relationships and fixing it on 21 teeth with glass ionomer cement (for example, Fuji). Recommendations are given.	Signature
^ Orthopedic treatment using a combined metal-plastic crown according to Belkin
27.02.09	Under infiltration anesthesia with 0.5 ml of a 4% solution of articaine with epinephrine, the 11th tooth was prepared for a stamped metal crown. Obtaining a two-phase impression with silicone impression material (for example, Speedex) from the upper jaw and an auxiliary impression with alginate impression mass (for example, Cromopan) from the lower jaw. Turnout 03/01/09	Signature
01.03.09	Fitting a metal stamped crown for 11 teeth. Under infiltration anesthesia with 0.7 ml of a 4% solution of articaine with epinephrine, additional preparation of the cutting edge of the vestibular and proximal surfaces of the 11th tooth was performed. Obtaining an imprint of the stump of the 11th tooth in a crown filled with wax. Obtaining a single-phase impression from the dentition of the upper jaw with a metal crown fitted with silicone impression mass (for example, Speedex). Selecting the color of the plastic cladding according to the Sinma plastic color scale (for example, color No. 14 + 19). Turnout 03/03/09.	Signature
03.03.09	Final fitting of the metal-plastic crown and fixing it on the 11th tooth with glass ionomer cement (for example, Fuji). Recommendations are given.	Signature
^ Orthopedic treatment using a cast all-metal crown
27.02.09	Under general anesthesia with 1.0 ml of a 4% solution of articaine with epinephrine, the 37th tooth was prepared for a cast all-metal crown. Gum retraction using a mechanochemical method using a retraction cord impregnated with epinephrine. Obtaining a working two-phase impression using silicone impression compound (for example, Speedex) from the upper jaw and an auxiliary impression with alginate impression mass (for example, Cromopan) from the lower jaw. Turnout 03/04/09.	Signature
04.03.09	Checking the quality of a cast all-metal crown, fitting it to the stump of the 37th tooth with correction of occlusal relationships in the central, anterior and lateral occlusions. No comments. Turnout 03/06/09.	Signature
06.03.09	Final fitting of the cast all-metal crown and its fixation on the 37th tooth with glass ionomer cement (for example, Fuji). Recommendations are given.	Signature
^ Orthopedic treatment using a metal-ceramic crown
27.02.09	Under infiltration anesthesia with 1.3 ml of a 4% solution of articaine with epinephrine, teeth 11 and 21 were prepared for metal-ceramic crowns. Gum retraction using impregnated retraction cords. Obtaining a working two-phase impression using silicone impression compound (for example, Speedex) from the upper jaw and an auxiliary impression with alginate impression mass (for example, Cromopan) from the lower jaw. Fitting and fixing standard temporary provisional crowns on the stump of 11, 12 teeth with water-based dentin. Turnout 03/04/09.	Signature
04.03.09	Fitting of cast metal caps on supporting teeth 11, 21. Selecting the color of the ceramic coating according to the Chromascope color scale. Fixation of temporary provisional crowns on the stump of 11, 12 teeth with water-based dentin. Turnout 03/06/09.	Signature
06.03.09	Checking the design and fitting metal-ceramic crowns for teeth 11 and 21. Correction of occlusal relationships in central, anterior and lateral occlusions. No comments. Fixation of temporary provisional crowns on the stump of 11, 12 teeth with water-based dentin. Turnout 03/07/09.
07.03.09	Final fitting and fixation of metal-ceramic crowns on the supporting teeth 11, 21 with glass ionomer cement (for example, Fuji). Recommendations are given.
^ Orthopedic treatment using an artificial crown on a cast stump pin inlay made by direct method
27.02.09	Preparation of the stump of the 13th tooth. Root canal preparation. Modeling a pin insert with wax Lavax. Temporary filling made of water-based dentin. Turnout 03/04/09.	Signature
04.03.09	Fitting and fixing the cast stump pin insert in the root canal of the 13th tooth with phosphate cement (for example, Uniface). Turnout 03/05/09.	Signature
05.03.09	Additional preparation of the stump of the 13th tooth. Gum retraction using a retraction cord impregnated with epinephrine. Obtaining a working two-phase impression using silicone impression compound (for example, Speedex) from the upper jaw and an auxiliary impression with alginate impression mass (for example, Cromopan) from the lower jaw for the manufacture of a metal-ceramic crown for the 13th tooth. Fitting and fixing a standard temporary provisional crown on the stump of the 13th tooth with water-based dentin. Turnout 03/09/09.	Signature
09.03.09	Checking the design and fitting the cast metal cap to the stump of the 13th tooth. Selecting the color of the ceramic coating according to the Chromascope color scale. Fixation of a temporary crown on the stump of the 13th tooth with water-based dentin. Turnout 03/12/09.
12.03.09	Checking the design and fitting the metal-ceramic crown for 13 teeth. Correction of occlusal relationships in central, anterior and lateral occlusions. No comments. Fixation of a temporary provisional crown on the stump of the 13th tooth with water-based dentin. Turnout 03/13/09.
13.03.09	Final fitting and fixation of the metal-ceramic crown on the stump of the 13th tooth with glass ionomer cement (for example, Fuji). Recommendations are given.	Signature
^ Orthopedic treatment using an artificial crown on a cast stump pin inlay made indirectly
27.02.09	Preparation of the stump of the 26th tooth. Preparation of root canals. Introduction of corrective silicone impression mass (for example, Speedex) into the root canals using a canal filler. Obtaining a two-phase impression with imprints of root canals using silicone impression compounds Speedex. Temporary filling made of water-based dentin. Turnout 03/04/09.	Signature
04.03.09	Fitting a dismountable stump pin insert with a sliding pin in the root canals of the 26th tooth, its fixation with glass ionomer cement (for example, Fuji). Turnout 03/05/09.	Signature
05.03.09	Additional preparation of the stump of the 26th tooth. Gum retraction using impregnated retraction cord. Obtaining a working two-phase impression from the upper jaw with silicone impression material (for example, Speedex), auxiliary – with lower alginate impression mass (for example, Orthoprint) for the manufacture of a cast all-metal crown for the stump of the 26th tooth. Turnout 03/06/09.	Signature
09.03.09	Checking the design and fitting the cast all-metal crown on the stump of the 26th tooth. Correction of occlusal relationships. No comments. Turnout 03/07/09.
11.03.09	Final fitting and fixation of the cast all-metal crown on the artificial stump of the 26th tooth with glass ionomer cement (for example, Fuji). Recommendations are given.

The final section of the medical history of a dental patient "Epicrisis" filled out according to a specific pattern:

Patient (full name) 02/27/09 went to the orthopedic dentistry clinic with complaints about _______________________________________.

Based on the examination data, the following diagnosis was made: _________________________________________________________________.

Orthopedic treatment was carried out ___________________________________

____________________________________________________________

The anatomical shape of the tooth crowns, the integrity of the dentition of the upper jaw, lost functions and aesthetic standards have been restored.

The medical history is completed by the signature of the doctor and, preferably, the head of the department.

PRACTICAL GUIDE FOR DOCTORS(advanced medical technologies)Printed by decision of the Methodological Council

GOU DPO KSMA Roszdrav

Approved

Ministry of Health

Republic of Tatarstan

Minister A.Z. Farrakhov

Reviewers:

Doctor of Medical Sciences, Professor R.Z. Urazova

Doctor of Medical Sciences, Associate Professor T.I. Sadykova

Kazan: 2008

Introduction

"Medical record of a dental patient" refers to medical documentation, form No. 043/u, which is indicated on the front page of the form. Before the patient’s medical history begins, the official name of the medical institution is indicated on the front side of the card, the registration number is affixed, and the date of its compilation is noted.

Dental diseases are one of the most common pathologies, which forces you to seek help from a dentist.

The goals of examining a patient with pathology of hard dental tissues are to assess the general condition of the body, clinical characteristics of the teeth, identify general and local etiological and pathogenetic factors, determine the form and nature of the course and localization of the pathological process.

The most complete information allows you to correctly diagnose the disease and effectively plan complex treatment and prevention. The doctor obtains the necessary set of differential diagnostic indicators by carefully collecting anamnesis, a detailed clinical examination, and using additional examination methods and laboratory research methods.

When filling out a dental patient’s medical record, it is necessary to take into account the “Medico-economic standards for therapeutic dentistry”, developed in the Republican Dental Clinic of the Ministry of Health of the Republic of Tatarstan for the region in 1998 on the basis of clinical and statistical groups in dentistry approved by the Ministry of Health of the Russian Federation in 1997. There is an order of the Ministry of Health of the Republic of Tatarstan No. 360 dated April 24, 2001. paragraph 2, which approves “methodological recommendations for filling out a dental patient’s medical record.”

Currently, there are already standards for "Dental caries", approved by the Ministry of Health and Social Development of the Russian Federation on October 17, 2006.

Case history diagram

General information (Profile details).

1. Last name, first name, patronymic of the patient

2. Age, year of birth

4. Place of work

5. Position held

6. Home address

7. Date of visit to the clinic

8. Informed voluntary agreement to the proposed treatment plan (this is not in the medical record and, most likely, should be included as an appendix).

I.Patient's complaints.

1. Main complaints.

These are complaints that bother the patient in the first place and are most characteristic of this disease. As a rule, the patient complains of pain. It is necessary to find out the following criteria for a pain symptom:

a) localization of pain;

b) pain is spontaneous or causal;

c) the reason for the appearance or intensification of pain;

d) intensity and nature of pain (aching, tearing, throbbing);

e) duration of pain (periodic, paroxysmal, constant)

f) presence or absence of night pain;

g) presence or absence of irradiation of pain, area of irradiation;

h) duration of painful attacks and light intervals;

i) factors that relieve pain;

j) the presence or absence of pain when biting a tooth (if

if there is no lei, then indicate that the diseased tooth was discovered during the examination);

k) were there any exacerbations, what were their causes.

2. Additional complaints

These are data that are not related to the main complaints and are usually a consequence of some physical disease. Additional complaints are identified actively, according to a scheme, in a certain sequence:

2.1 Digestive organs.

1. Feeling of dry mouth.

2. The presence of increased salivation.

3. Thirst: how much fluid does he drink per day?

4. Taste in the mouth (sour, bitter, metallic, sweetish, etc.)

5. Chewing, swallowing and origin of food: free, painful, difficult. What food does not pass through (solid, liquid).

6. Bleeding from the oral cavity: spontaneous, when brushing teeth, when eating hard foods, absent.

7. Having bad breath.

3. Complaints that determine the general condition

General weakness, malaise, unusual fatigue, increased body temperature, decreased performance, weight loss (how much and over what period).

II.History of the present disease.

The occurrence, course and development of the present disease from the moment of its first manifestations to the present.

1. When, where and under what circumstances the disease occurred.

2. What does the patient associate his illness with?

3. Onset of the disease - acute or gradual.

4. First symptoms.

5. The initial symptoms of the disease, their dynamics, the appearance of new symptoms, their further development until the moment of contacting the therapeutic dentistry clinic and the beginning of the present examination of the patient are described in detail, in chronological order. In the chronic course of the disease, it is necessary to find out the frequency of exacerbations, the reasons that cause them, the relationship between the time of year or other factors. The presence or absence of progression of the disease as exacerbations occur.

6. Diagnostic and therapeutic measures based on medical history (old radiographs, records in the outpatient card, etc.). What diagnosis was made? Duration and effectiveness of previous treatment.

7. Characteristics of the period preceding the present application to the therapeutic dentistry clinic. Have you been registered at a dispensary, or received preventive treatment (what and when). Last exacerbation (for chronic diseases), time of onset, symptoms, previous treatment.

III.History of the patient's life.

The purpose of this stage is to establish the connection of the disease with external factors, living conditions, and previous diseases.

1. Place of birth.

2. Material and living conditions in childhood (where, how and in what conditions he grew up and developed, the nature of feeding, etc.).

3. Work history: when you started working, the nature and conditions of work, occupational hazards in the past and present. Subsequent changes in work and place of residence. Detailed description of the profession. Work indoors or outdoors. Characteristics of the working area (temperature, its fluctuations, drafts, dampness, lighting, dust, contact with harmful substances). Working hours (day work, shift work, length of working day). Psychological atmosphere at work and at home, use of weekends and vacations.

4. Current living conditions.

5. The nature of the diet (regular or not, how many times a day, at home or in the dining room), the nature of the food taken (sufficiency, addiction to certain foods).

6. Habitual intoxications: smoking (from what age, number of cigarettes per day, what one smokes); drinking alcohol; other bad habits

7. Previous diseases, injuries of the maxillofacial area and a detailed description of previous and concomitant diseases from early childhood before admission to the therapeutic dentistry clinic, indicating the year of the disease, the duration and severity of the complications that arose, as well as the effectiveness of the treatment. A separate question about past sexually transmitted diseases, tuberculosis, hepatitis.

8. Illnesses of immediate relatives. State of health or cause of death (indicating life expectancy) of parents and other close relatives. Pay special attention to tuberculosis, malignant neoplasms, diseases of the cardiovascular system, syphilis, alcoholism, mental illness, and metabolic disorders. Create a genetic picture.

9. Tolerance of drugs. Allergic reactions.

Information obtained from collecting anamnesis is often crucial for clarifying the diagnosis. It should be emphasized that the anamnesis must be active, that is, the doctor must ask the patient purposefully, and not listen to him passively.

Objective examination data

An objective examination consists of inspection, palpation, probing and percussion.

I. Inspection.

When examining, pay attention to:

1. General condition (good, satisfactory, moderate, severe, very severe).

2. Type of constitution (normosthenic, asthenic, hypersthenic).

3. Facial expression (calm, excited, indifferent, mask-like, suffering).

4. Patient’s behavior (sociable, calm, irritable, negative).

5. Presence or absence of asymmetry.

6. Condition of the red border of the lips and corners of the mouth.

7. Degree of mouth opening.

8. The patient’s speech (intelligible, slurred)

9. Skin and visible mucous membranes:

color (pale pink, dark, red, pale, jaundiced, cyanotic, earthy, brown, dark brown, bronze (indicate places of color on visible skin, etc.);
skin depigmentation (leukoderma), albinism;
swelling (consistency, severity and distribution);
turgor (elasticity) of the skin (normal, reduced);
degree of humidity (normal, high, dry). The degree of moisture in the oral mucosa;
rashes, rashes (erythema, spot, roseola, papule, pustule, blister, scales, crust, cracks, erosions, ulcers, spider veins (indicating their location);
scars (their nature and mobility)
external tumors (atheroma, angioma) - location, consistency, size.

10. Lymph nodes:

localization and number of palpable nodes: occipital, parotid, submandibular, chin, cervical (anterior, posterior);
pain on palpation;
shape (oval, irregular round);
surface (smooth, bumpy);
consistency (hard, soft, elastic, homogeneous, heterogeneous);
welded to the skin, surrounding fiber and their mobility among themselves;
size (in mm);
condition of the skin above them (color, temperature, etc.).

II. Plan and sequence of oral examination.

A healthy person has a symmetrical face. The lips are quite mobile, the upper one does not reach the cutting edges of the upper front teeth by 2-3 mm. Opening the mouth and moving the jaws are free. Lymph nodes are not enlarged. The actual mucous membrane of the mouth is pale pink or pink in color, does not bleed, fits tightly to the teeth, and is painless.

After a general examination of the external parts of the maxillofacial region, the vestibule of the mouth is examined, then the condition of the dentition.

The examination usually begins with the right half of the upper jaw, then examines its left side, the lower jaw on the left; complete the examination on the right side in the retromolar area of the lower jaw.

When examining the vestibule of the mouth, pay attention to its depth. To determine the depth, measure the distance from the edge of the gum to its bottom with a graduated instrument. The vestibule is considered shallow if its depth is no more than 5 mm, medium - 8-10 mm, deep - more than 10 mm.

The frenulum of the upper and lower lips is attached at a normal level. During the examination of the frenulum of the lips and tongue, attention is paid to their anomalies and the height of their attachment.

When assessing the dentition, attention is paid to the type of bite: orthognathic, prognathic, progynic, micrognothia, straight. Separately, the uniformity of teeth closure and the presence of dentoalveolar anomalies, diastemas and three are noted.

The teeth fit tightly to each other and, thanks to contact points, form a single gnathodynamic system. When examining teeth, the presence of plaque is noted, indicating its color, shade and location of stains, relief and defects of enamel, the presence of foci of demineralization, carious cavities and fillings.

III. The most common clinical dental designation systems.

1. Standard square-digital Zygmandy-Palmer system. It provides for the division of the dentofacial system (dentition) into 4 quadrants along the sagittal and occlusal planes. When recorded in a chart, each tooth is indicated graphically, accompanied by an angle corresponding to the location of the tooth in the formula.

This formula is not used. However, the examination of the teeth/dentition is carried out in exactly this sequence: from the right upper jaw to the right lower jaw.

3. When recording on the map, each tooth is indicated by letters and numbers in the following order: first the jaw is indicated, then its side, the tooth number according to its location in the formula.

5. Designations of parts of the oral cavity. For this purpose, codes are used according to accepted WHO standards:

01 - upper jaw

02 - lower jaw

03 - 08 - sextants in the oral cavity in the following order:

sextant 03 - upper right rear teeth

sextant 04 - upper canines and incisors

sextant 05 - upper left rear teeth

sextant 06 - lower left rear teeth

sextant 07 – lower canines and incisors

sextant 08 - lower right rear teeth.

V. Designations of various types of dental lesions.

These designations are entered into the map above or below the corresponding tooth:

C - caries

P - pulpitis

Pt - periodontitis

R - root

F - fluorosis

G - hypoplasia

Cl - wedge-shaped defect

O - missing tooth

K - artificial crown

I - artificial tooth

VI. Probing.

This procedure is carried out using a dental probe. This allows you to make a judgment about the nature of the enamel and identify defects on it. The probe determines the density of the bottom and walls of the cavity in the hard tissues of the teeth, as well as their pain sensitivity. Probing makes it possible to judge the depth of the carious cavity and the condition of its edges.

VII. Percussion.

The method allows you to determine whether there is an inflammatory process in the periapical tissues, as well as complications after filling the proximal surface of the tooth.

VIII. Palpation.

The method is used to detect swelling, the presence of infiltration on the alveolar process or along the transitional fold.

Additional research methods

To make an accurate diagnosis and carry out differential diagnosis of dental diseases, it is necessary to carry out additional examination methods.

I. Assessment of the hygienic state of the oral cavity.

Determining the level of oral hygiene plays an important role in diagnosing and predicting the effectiveness of treatment and preventive measures in dentistry. To assess the hygienic state of the oral cavity, it is recommended to calculate the following hygienic indices (IGPR).

1. The Fedorov-Volodkina hygienic index (written on the card: GI FV) is expressed in two numbers that determine quantitative and qualitative characteristics. This index is determined by the intensity of the color of the labial surface of the six lower frontal teeth (with a solution of methylene blue or Pisarev-Schiller solution).

1.1. Quantitative assessment is carried out using a five-point system:

staining the entire surface of the tooth - 5 points,

3/4 surface - 4 points,

1/2 surface - 3 points,

1/4 surface - 2 points,

absence of staining - 1 point.

The hygienic condition is considered good with a quantitative index value of 1.0 points, with a value of 1.1-2.0, satisfactory, and with a value of 2.1-5.0, unsatisfactory.

1.2. Qualitative assessment:

no staining - 1 point,

weak staining - 2 points,

intense coloring - 3 points.

The hygienic condition is considered good with an index value of 1 point, with a value of 2, satisfactory, and with a value of 3, unsatisfactory.

2. Green & Vermillion Hygiene Index (written on the card: IG GV). Using the authors' method, a simplified hygiene index (OHI-S) is determined, which includes the plaque index and tartar index.

2.1. The dental plaque index is determined and calculated by the intensity of coloring of the surface of the following teeth: buccal - 16 and 26, labial -11 and 31, lingual -36 and 46. Quantitative assessment of the index is carried out using a three-point system:

0—no staining;

1 point - dental plaque covers no more than 1/3 of the tooth surface;

2 points - dental plaque covers more than 1/3, but not more than 2/3 of the tooth surface;

3 points - dental plaque covers more than 2/3 of the tooth surface.

2.2. The tartar index is determined and calculated by the amount of supragingival and subgingival hard deposits on the same group of teeth: 16 and 26, 11 and 31, 36 and 46.

1 point - supragingival calculus is detected on one surface of the examined tooth and covers up to 1/3 of the height of the crown;

2 points - supragingival calculus covers the tooth on all sides from 1/3 to 2/3 of the height, as well as when particles of subgingival calculus are detected;

3 points - if a significant amount of subgingival tissue is detected

stone and in the presence of supragingival stone covering the tooth crown more than 2/3 of the height.

The Green-Vermillion Combined Index is calculated as the sum of the plaque and tartar indices. Each indicator is calculated using the formula:

By Wed. = K and / n

Kcf - general indicator of dental cleanliness

K and - indicator of the degree of coloration of one tooth

n is the number of teeth being examined

The hygienic condition is considered good with an index value of 0.0, with a value of 0.1-1.2, satisfactory, and with a value of 1.3-3.0, unsatisfactory.

To assess this index, the vestibular surfaces of teeth 16, 11, 26, 31 and the lingual surfaces of teeth 36 and 46 are stained. The examined tooth surface is conventionally divided into 5 sections: central, medial, distal, mid-occlusal, mid-cervical. Each section is assessed in points:

0 points - no staining

1 point - coloring of any intensity

The Hygiene Performance Index is calculated using the formula:

The hygienic condition with an index value of 0 is assessed as excellent hygiene, with an index value of 0.1-0.6 as good, with an index value of 0.7-1.6 as satisfactory, with an index value of more than 1.7 it is considered unsatisfactory .

Determination of the rate of formation is carried out by staining the the following surfaces of the teeth (tooth) with Lugol's solution. First, controlled cleaning of the surfaces of the teeth being examined is carried out. Subsequently, the teeth are examined for 4 days and then the surfaces of the same teeth are re-stained.

The degree of coverage of these surfaces with soft plaque is assessed using a five-point system. The difference in staining rates with Lugol's solution on the surfaces of the teeth under study between days 4 and 1 reflects the rate of its formation.

This difference, expressed less than 0.6 points, indicates the resistance of teeth to caries, and a difference of more than 0.6 points indicates the susceptibility of teeth to caries.

II. Vital staining of hard dental tissues.

The technique is based on increasing the permeability, in particular of large molecular compounds. Designed to identify those affected by caries in the early stages of its development. Upon contact with solutions of dyes in areas of demineralized hard tissues, the dye is sorbed, while unchanged tissues are not stained. A 2% aqueous solution of methylene blue is usually used as a dye.

To prepare a solution of methylene blue, add 2 g of dye to a 100 ml volumetric flask and add distilled water to the mark.

The surface of the teeth to be examined is thoroughly cleaned of soft dental plaque with a swab moistened with a 3% solution of hydrogen peroxide. The teeth are isolated from saliva, dried, and cotton swabs soaked in a 2% solution of methylene blue are applied to the prepared enamel surface. After 3 minutes, the dye is removed from the surface of the tooth using cotton swabs or rinsing.

According to E.V. Borovsky and P.A. Leus (1972) distinguishes between light, medium and high degrees of coloration of carious spots; this corresponds to a similar degree of enamel demineralization activity. Using a gradation ten-field halftone scale of various shades of blue, the color intensity of carious spots: the least colored stripe is taken as 10%, and the most saturated - as 100% (Aksamit L.A., 1974).

In order to determine the effectiveness of treatment of initial caries, re-staining is carried out at any time intervals.

III. Determination of the functional state of enamel.

The functional state of enamel can be judged by the composition of the hard tissues of teeth, their hardness, resistance to acids and other indicators. In clinical settings, methods for assessing the resistance of dental hard tissues to acids are becoming widespread.

1. TER test.

The most acceptable method is V.R. Okushko (1990). A drop of 1 normal hydrochloric acid with a diameter of 2 mm is applied to the surface of the central upper incisor, washed with distilled water and dried. After 5 seconds, the acid is washed off with distilled water and the tooth surface is dried. The depth of the enamel etching microdefect is assessed by the intensity of its staining with a 1% solution of methylene blue.

The etched area appears blue. The degree of coloring reflects the depth of damage to the enamel and is assessed using a blue standard printing scale. The more intensely the etched area is colored (from 40% and above), the lower the acid resistance of the enamel.

2. KOSRE-test (Clinical assessment of the rate of remineralization of ema-

This test is designed to determine the resistance of teeth to caries (Ovrutsky G.D., Leontyev V.K., Redinova T.L. et al., 1989). Based on an assessment of both the condition of tooth enamel and the remineralizing properties of saliva.

The enamel surface of the tooth being examined is thoroughly cleaned of plaque with a dental spatula and a 3% hydrogen peroxide solution, and dried with compressed air. Then a drop of hydrochloric acid buffer pH 0.3-0.6 is applied to it, always in a constant volume. After 1 minute, the demineralizing solution is removed with a cotton swab. A cotton ball soaked in a 2% solution of methylene blue is also applied to the etched area of tooth enamel for 1 minute. The compliance of enamel to the action of acid is assessed by the intensity of staining of the etched area of tooth enamel. After 1 day, the etched area of tooth enamel is re-stained without repeated exposure to the demineralizing solution. If the etched area of tooth enamel becomes stained, then this procedure is repeated again after 1 day. The loss of the etched area's ability to stain is regarded as a complete restoration of its mineral composition.

The acid buffer is a demineralizing solution. To prepare it, take 97 ml of 1 normal hydrochloric acid and 50 ml of 1 normal potassium hydrochloride, mix and adjust the volume to 200 ml with distilled water. To give greater viscosity, one part of glycerin is added to one part of this solution. Increased viscosity helps to obtain a drop of it with a constant amount of contact with the tooth and better retention of it on the surface. For better visual control, the demineralizing liquid is tinted with acid fuchsin. In this case, the demineralizing solution becomes red.

The degree of compliance of tooth enamel to the action of acid is taken into account as a percentage, and the remineralizing ability of saliva is calculated in days. People's resistance to caries is characterized by low compliance of tooth enamel to acid action (below 40%) and high remineralizing ability of saliva (from 24 hours to 3 days), and those susceptible to caries are characterized by high compliance of tooth enamel to the action of acid (above or equal to 40%) and low remineralizing ability of saliva (more than 3 days).

IV. Index of intensity of dental caries damage.

The intensity of caries is determined by the average number of carious teeth per person. The intensity is calculated according to the KPU index: K - caries, P - fillings, U - extracted teeth. Depending on the activity of the carious process, WHO distinguishes 5 degrees:

Caries intensity (ICU)
indicators
indicators		from 35 years to 44 years
very low
low
moderate
high
very high	6.6 or more	16.3 or more

In childhood, to specify the implementation of preventive measures, it is recommended to adhere to the methodology of T.F. Vinogradova, when the intensity of caries is determined by the degree of caries activity using the indices KP (during the period of temporary dentition), KPU + KP (during the period of mixed dentition) and KPU (during the period of permanent dentition).

The first degree of caries activity (compensated form) is a condition of the teeth when the index CP or CP + CP or CP does not exceed the average intensity of caries corresponding to the age group; There are no signs of focal demineralization and initial caries identified by special methods.
The second degree of caries activity (subcompensated form) is a condition of the teeth in which the intensity of caries according to the indices kp or kpu + kp or kp is greater than the average intensity value for a given age group by three signal deviations. At the same time, there is no actively progressing focal demineralization of enamel and initial forms of caries.
The third degree of caries activity (decompensated form) is a condition in which the indicators of the CP or CP + CP or CP index exceed the maximum value or, with a lower value of the CP, actively progressing foci of demineralization and initial caries are detected.

Thus, the intensity of caries according to the degree of activity is assessed by the following indicators:

1st degree - index up to 4 (compensated)

2nd degree - index from 4 to 6 (subcompensated)

V. Thermometric study.

Thermometry determines the reaction of tooth tissue to the action of thermal stimuli.

An intact tooth with a healthy pulp reacts painfully to temperatures below 5-10°C and above 55-60°C.

Cold compressed air can be used to test the tooth's response to cold. However, it is sometimes difficult to determine which tooth responds to a thermal stimulus.

It is more objective when a cotton swab, previously immersed in cold or hot water, is brought into the carious cavity or applied to the tooth.

VI. Electroodontometry (EOM).

Using this method, the sensitivity threshold of the dental pulp to electric current is determined, which reflects the viability of the pulp. The minimum current that causes tissue irritation is called the irritation threshold. Electroodontometry is especially important for excluding complicated caries. The method can also be used to check the depth of anesthesia.

The study is carried out from sensitive points: at the incisors from the cutting edge, at premolars and molars from the tubercles.

An intact tooth responds to currents from 2 to 6 μA. With the development of pathological processes, the threshold of irritation (electrical excitability) changes. When the sensitivity threshold of the pulp decreases, the digital indicators increase. A pronounced decrease in the sensitivity of the dental pulp to 35 μA occurs in acute deep caries; up to 70 µA the pulp is viable, and more than 100 µA there is complete necrosis of the pulp. Each tooth is examined 2-3 times, after which the average current strength is calculated.

The method for determining the sensitivity of dental pulp to electric current is quite informative, however, it must be taken into account that its implementation may give a false-negative reaction in the following cases:

for tooth pain relief;
if the patient is under the influence of analgesics, drugs, alcohol or tranquilizers;
with incomplete root formation or its physiological resorption (in these cases, the nerve endings of the pulp are not sufficiently formed or are in the stage of degeneration and respond to a much higher current strength than the pulp of a healthy tooth);
after a recent injury to the tooth (due to pulp concussion);
in case of inadequate contact with enamel (through a composite filling);
with a heavily calcified canal.

In addition, in some cases, there is a decrease in electrical excitability in intact teeth (in wisdom teeth, in teeth that do not have antagonists located outside the arch, in the presence of petrification in the pulp). Inaccurate electroodontometry readings may be due to variability in the blood supply to the pulp, a false reaction due to stimulation of nerve endings in the periodontium during pulp necrosis. In molars, a combination of living and dead pulp in different canals is possible. Results may not be true in persons with mental disorders who are unable to respond adequately to mild pain.

The likelihood of error can be reduced by comparative electroodontometry, simultaneous examination of antimer teeth and other obviously healthy teeth, as well as the placement of electrodes alternately on all cusps of the chewing tooth being studied.

This study strictly contraindicated! persons with an implanted heart pacemaker.

VII. Transillumination.

Transillumination, based on the unequal light-absorbing ability of various structures, is carried out by passing rays of light by “transilluminating” the tooth from the palatal or lingual surface. The passage of light through the hard tissues of teeth and other tissues of the oral cavity is determined by the laws of optics of turbid media. The method is based on the assessment of shadow formations that appear when a cold beam of light, harmless to the body, passes through the tooth. Transillumination is especially effective when illuminating single-rooted teeth.

When examined in rays of transmitted light, signs of caries damage are detected, including “hidden” carious cavities. In the initial stages of the lesion, they usually appear in the form of grains of various sizes from pinpoint to the size of a millet grain and larger, with uneven edges from light to dark color. Depending on the location of the initial caries focus, the transillumination pattern changes. With fissure caries, the resulting image reveals a dark, blurry shadow, the intensity of which depends on the severity of the fissures; with deep fissures, the shadow is darker. On the proximal surfaces, the affected areas have the appearance of characteristic shadow formations in the form of hemispheres of brown light, clearly delimited from healthy tissue. On the cervical and bucco-lingual (palatal) surfaces, as well as on the mounds of chewing teeth, lesions appear in the form of small-sized darkenings that appear against a light background of intact hard tissues.

In addition, when using the method, it is possible to detect the presence of calculus in the tooth cavity and foci of subgingival tartar deposition.

VIII. Luminescent diagnostics.

This method of using ultraviolet irradiation is based on the effect of luminescence of hard dental tissues and is intended for the diagnosis of initial caries and is based.

Under the influence of ultraviolet rays, luminescence of tooth tissue occurs, characterized by the appearance of a delicate light green color. Healthy teeth glow snow-white. Areas of hypoplasia give a more intense glow compared to healthy enamel and give a light green tint. In the area of foci of demineralization, light and pigmented spots, a noticeable quenching of luminescence is observed.

IX. X-ray examination.

It is used when there is a suspicion of the formation of a carious cavity on the approximal surface of the tooth and when the teeth are closely spaced, when the hard tissue defect is inaccessible to inspection and probing. This method is used for all forms of pulpitis, apical periodontitis, as well as for monitoring the filling of root canals after treatment and dynamic monitoring of the apical focus of destruction.

The variety of x-ray research methods requires the dentist to be able to choose a method that provides maximum information regarding the patient being examined.

1. Traditional methods of x-ray examination. The basis of traditional x-ray examination for most dental and periodontal diseases is still intraoral radiography. This method is the simplest and least radiation-safe, using X-ray machines, where the image is recorded on film. There are currently 4 intraoral radiography techniques:

radiography of periapical tissues in isometric projection;
radiography from an increased focal length with a parallel beam of rays;
interproximal radiography;
X-ray in bite.

2. Radiophysiography. For this research method, X-ray machines with a filmless visual inspection system are used. They are called dental computed radiography (DCR) or radiophysiography. The IFR system includes touch sensors that operate in accordance with a computer program that controls image capture and storage. Radiophysiography is superior to conventional radiography in terms of speed, image quality and reduced radiation exposure. The SKR system program allows you to manipulate the resulting image:

4x or more magnification, which allows you to see small details;
local magnification, which allows you to select individual fragments;
highlighting a specific area;
image alignment;
a negative image can be transformed into a positive one;
dye in a range of colors, which makes it possible to determine the density of the fabric;
optimize the contrast of the object being studied;
make the image embossed;
conduct pseudoisometry, that is, obtain a pseudo-volume image.

The program also has a measuring object function, which allows you to take the necessary measurements and enter them as marks directly on the image.

3. Panoramic radiography. This method makes it possible to simultaneously obtain in one image a detailed image of the entire dentition of both the upper and lower jaws. Such an x-ray allows you to obtain a significantly larger amount of information.

4. Orthopantomography. This type of research is based on the tomographic effect. The result is a detailed image of the upper and lower jaws. The study area usually also includes the lower parts of the maxillary sinuses, temporomandibular joints, and pterygopalatine fossa. From the image it is easy to assess the condition of the upper and lower dentition, their relationships, and identify intraosseous pathological formations. From an orthopantomogram it is possible to calculate periapical index, which can have the following values:

1 point - normal apical periodontium,

2 points - bone structural changes indicating pe-

riapecal periodontitis, but not typical for it,

3 points - bone structural changes with some loss

mineral part, characteristic of the apical pe-

rhiodonta,

4 points - clearly visible enlightenment,

5 points - enlightenment with radical spread of co-

nal structural changes.

X.Laboratory research methods.

1. Determination of pH of oral fluid.

To determine pH, 20 ml of oral fluid (mixed saliva) is collected in the morning on an empty stomach.

The pH test is carried out three times, followed by calculation of the average result.

A decrease in the pH of oral fluid with a shift to the acidic side is considered a sign of active progressive dental caries.

An electronic pH meter was used to study the pH of oral fluid.

2. Determination of saliva viscosity.

Mixed saliva is collected after stimulation by ingesting 5 drops of a solution of 0.3 g of pilocarpine in 15 ml of water. Local pilocarpinization can also be carried out by introducing a small cotton swab moistened with 3-5 drops of a 1% pilocarpine solution into the oral cavity for 10 minutes. For the study, take 5 ml of saliva just obtained after collection. Along with saliva viscometry, water testing is carried out.

The viscosity of saliva is judged by the formula:

t 1 — saliva viscometry time

t 2 - water viscometry time

The average value of V is 1.46 with very significant fluctuations from 1.06 to 3.98. A V value above 1.46 is an unfavorable prognostic indicator for caries.

An Oswald viscometer is used, using a capillary 10 cm long and 0.4 mm in diameter. To obtain accurate results, before adding saliva to the viscometer, it is immersed in water at a temperature of 37°C for 5 minutes.

3. Determination of lysozyme activity in saliva.

Parotid and mixed saliva are collected at the same time of day - in the morning. Mixed saliva was collected by spitting into test tubes after preliminary rinsing of the mouth. Parotid saliva was collected after stimulation with citric acid using a special device proposed by V.V. Gunchev and D.N. Khairullin (1981). The test saliva is diluted with phosphate buffer in a ratio of 1:20, and the secretion of small salivary glands in a ratio of 1:200.

The activity of lysozyme in mixed and parotid saliva is determined by the photonephelometric method according to V.T. Dorofeychuk (1968).

3. Determination of the level of secretory immunoglobulin A in saliva.

Glass plates measuring 9 x 12 cm are covered with a uniform layer of a mixture of “3% agar + monospecific serum”. In the agar layer, holes with a diameter of 2 mm are created with a punch at a distance of 15 mm from one another. The wells of the first row were filled with 2 μl of standard serum using a microsyringe in dilutions of 1: 2, 1: 4, 1: 8. The wells of the next rows were filled with the test saliva. The plates are incubated in a humid chamber for 24 hours at a temperature of +4°C. At the end of the reaction, the diameters of the precipitation rings are measured. The immunoglobulin content was determined relative to the standard secretory immunoglobulin A serum S-JgA.

The level of secretory immunoglobulin A (S-JgA) in mixed saliva is determined by the method of radial immunodiffusion in a gel according to Manchini (1965) using monospecific serum against human secretory immunoglobulin A produced by the Research Institute of Experimental Physics. N.F. Gamaleya.

Mandatory inserts in the medical record of a dental patient

Filling out a dental patient's medical record requires strict adherence to the orders and instructions of the Ministry of Health of the Republic of Tatarstan.

There are three required inserts in a dental patient's medical record.

In accordance with the order of the Ministry of Health of the Republic of Tajikistan No. 2 dated January 10, 1995, the form “Examination of a patient for syphilis” was introduced. When filling out this insert

Attention is drawn to the patient's characteristic complaints. An objective examination involves palpation of the submandibular and cervical lymph nodes. The condition of the mucous membrane of the oral cavity, tongue and lips is especially carefully assessed. The presence of erosions, ulcers and cracks in the corners of the mouth (jam) of unknown etiology requires mandatory referral of the patient for examination for syphilis with a corresponding entry in the chart.

In accordance with the order of the Ministry of Health of the Republic of Tajikistan No. 780 dated August 18, 2005, the “Form for oncological preventive medical examination” was introduced. Particular attention is paid to the condition of the lips, mouth and pharynx, lymph nodes, and skin. If cancer or a precancerous disease is suspected, the “+” symbol is placed in the appropriate column, after which the patient is sent to an oncological treatment facility.

The insert “Dosimetric monitoring of a patient’s ionizing radiation” records radiation doses during X-ray examinations of teeth and jaws. This form was developed on the basis of a sheet for recording patient dose loads during X-ray examinations, which complies with the requirements of SaNPin 2.6.1.1192-03.

Legal registration of the relationship between the institution (doctor) and the patient

After completing the examination of the dental patient, a diagnosis of the disease is established, which should be as complete as possible. In this case, each of the provisions of the diagnosis is substantiated.

This approach allows us to build a coherent system of complex treatment of the patient, taking into account all the factors influencing both the occurrence and development of this disease, as well as its course and prognosis.

The diagnosis is entered into the dental patient’s medical record with an explanation of the possible outcomes of the disease. The treatment plan is explained in detail to the patient, indicating the means and methods of treatment. Alternative treatments may be suggested if available. The timing of treatment and subsequent rehabilitation for this pathology is discussed separately.

The patient has the right to decide whether he agrees or disagrees with the treatment plan proposed to him, about which a corresponding note is made in the medical record.

Informed voluntary written consentfor medical intervention

Voluntary written consent is based on the Law “Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens,” which was adopted by the State Duma of the Russian Federation on July 22, 1993 No. 5487-1, Article 32.

Methodological recommendations of the Federal Compulsory Medical Insurance Fund of Russia dated October 27, 1999 No. 5470/30-ZI determine that the form of patient consent to medical intervention can be determined by the head of a healthcare institution or the territorial body of the Healthcare Administration of a constituent entity of the Russian Federation.

Failure papatient from medical intervention

Refusal of medical intervention is provided for in the Law “Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens,” which was adopted by the State Duma of the Russian Federation on July 22, 1993, No. 5487-1, Article 33.

Methodological recommendations of the Federal Compulsory Medical Insurance Fund of Russia dated October 27, 1999 No. 5470/30-ZI determine that the form of a patient’s refusal of medical intervention can be determined by the head of a healthcare institution or the territorial body of the Healthcare Administration of a constituent entity of the Russian Federation. As an option, a refusal form according to the Moscow City Law Office is offered.

V.Yu. Khitrov,N.I. Shaimieva, A.Kh. Grekov, S.M. Krivonos,

N.V. Berezina, I.T. Musin, Yu.L. Nikoshina

Card design standards (Moscow)

1).Medium caries:

Complaints: short-term pain from cold, sweet food.....(tooth formula)

Objectively: on…..(name) surface…..(tooth formula) is carious

cavity ..... Black class, made of softened dentin. Probing is painful along the dentinal-enamel border. Short-term pain from temperature stimuli. Percussion is negative.

Treatment: under topical anesthesia (................................... (name)) and

infiltration (conduction) anesthesia (…… (name)) is formed

and the cavity was treated with medication. ….(description of the

manipulations - filling (number of surfaces). restoration, tab, etc., with the name of the material and color indication)

2).Deep caries:

Complaints: the presence of a carious cavity, food ingress, short-term pain from cold in.....(tooth formula).

Objectively: on….(name) surface…(tooth formula) there is a carious cavity,…..according to Black, filled with softened dentin. Probing is slightly painful along the entire bottom of the carious cavity. Short-term pain from temperature stimuli. Percussion is negative.

Treatment: Under topical anesthesia (.... (name)) and

Infiltration (conduction) anesthesia (….. (name)) is formed

and the cavity was treated with medication. Medical pad.. (name).

Insulating gasket…. (Name). (description of the manipulations performed - filling, restoration, inlay, etc., with the name of the material and an indication of the color). Sanding,

polishing

3).Exacerbation of chronic pulpitis.

Complaints: Pulsating, prolonged pain, aggravated by temperature stimuli in... (tooth formula). Night pain.

Objectively: on…. (name) surface...(tooth formula) carious cavity filled with softened dentin, filling remains, food debris. Probing is sharply painful at one point. When probed, the pulp bleeds. Temperature stimuli cause sharp, trace pain. Percussion is negative.

Treatment: Under topical anesthesia….(name) and

with infiltration (conduction) anesthesia….. (name) the tooth cavity is opened. Amputation, extirpation. Root canals are mechanically and medicinally treated. Length (mm).... ISO..... Sealed (description of materials and technology)

Second visit: No complaints

Treatment: ....(description of manipulations, pin, gasket, filling, restoration, tab indicating materials and color)

4).Chronic fibrous pulpitis.

Complaints: the presence of a carious cavity, periodic spontaneous pain in.. (tooth formula).

Objectively: On...(name) surface....(tooth formula) there is a deep carious cavity communicating with the tooth cavity. Probing is slightly painful. When probing the pulp bleeds. Percussion is negative.

Treatment: Under application anesthesia...(name) and infiltration (conduction) anesthesia...(name) the tooth cavity is opened. Amputation, extirpation. Root canals are mechanically and medicinally treated. Length (mm).... ISO..... Sealed....(description of materials and technology).

RVG control: the root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary bandage.

Second visit:

No complaints.

Objectively: the temporary dressing has been preserved. Percussion is negative.

Treatment: ... (Description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

5).Chronic gangrenous pulpitis.

Complaints: Pain from hot foods, presence of a carious cavity in....(tooth formula)

Objectively: on... (name) surface....(tooth formula) is deeply carious

a cavity filled with gray contents communicating with the tooth cavity.

Probing in root canals is painful.

.(description of materials and technology).

RVG control: the root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary bandage.

Second visit:

No complaints

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment:...(description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

6).Chronic hypertrophic pulpitis.

Complaints: Mild pain from mechanical stimuli, bleeding from

...(tooth formula).

Objectively: On the (name) surface....(tooth formula) there is a deep carious cavity filled with granulation tissue. On probing, the pulp is slightly painful and bleeds.

Treatment: Under topical anesthesia (name) and

Infiltration (conduction) anesthesia (name) opens the tooth cavity. Amputation, extirpation. The root canals are mechanically and medicinally treated. Length (mm).... ISO..... sealed (description of materials and technology).

RVG control: The root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary bandage.

Second visit:

no complaints

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment: .(description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

7).Exacerbation of chronic periodontitis.

Complaints of constant pain that increases when biting, a feeling of an “overgrown tooth.”

Objectively: on the (name) surface....(tooth formula) there is a deep carious cavity communicating with the tooth cavity. Probing is painless. Percussion is sharply positive.

Infiltration (conduction) anesthesia (name) opens the tooth cavity. Evacuation of contents from the root canal. Root canals are mechanically and medicinally treated. Length (mm).... ISO.... Temporary

Second visit:

No complaints.

Objectively: The temporary dressing has been preserved. Percussion is negative.

Treatment: Under topical anesthesia (Name) and infiltration (conduction) anesthesia (name), removal of the temporary dressing. Medical treatment of root canals. The root canals are filled (description of materials and technology).

RVG control. The root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary bandage.

Third visit:

No complaints

Objectively: The temporary bandage is preserved. Percussion is negative.

Treatment: (description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

8).Chronic fibrous periodontitis.

Complaints: the presence of a carious cavity in....(tooth formula) food ingress.

Objectively: on the (name) surface....(tooth formula), there is a deep carious cavity communicating with the tooth cavity. Probing is painless. Percussion is negative. There is no pain from temperature stimuli.

RVG: widening of the periodontal gap.

Treatment: Under topical anesthesia (Name) and

Infiltration (conduction) anesthesia (name) opens the tooth cavity. Evacuation of contents from the root canal. Root canals are treated mechanically and medicinally. Length (mm).... ISO.... Temporary bandage.

Second visit.

no complaints.

Objectively: The temporary dressing has been preserved. Percussion is negative.

Treatment: Under topical anesthesia (name) and

infiltration (conduction) anesthesia (name) removal of temporary bandage. Medical treatment of root canals. Root

The canals are sealed (description of materials and technology). RVG control. The root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary bandage.

Third visit:

no complaints

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment: (description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

9).Chronic granulating periodontitis.

complaints: The presence of a carious cavity in....(tooth formula), food ingress

Objectively: on the (Name) surface (tooth formula), there is a deep carious cavity communicating with the tooth cavity. Probing is painless. Percussion is negative. There is no pain from temperature stimuli.

RVG: expansion of the periodontal fissure, in the area of the apex (which root) there is a focus of destruction with unclear contours.

Treatment: Under application anesthesia (name) and infiltration (conduction) anesthesia (name), the tooth cavity is opened. Evacuation of contents from the root canal. The root canals are mechanically and medicinally treated. Length (crowbar).... ISO.... Temporary

Second visit:

no complaints.

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment: Under topical anesthesia (name) and infiltration (conduction) anesthesia (name) Removal of the temporary bandage. Medical treatment of root canals. Root canals are sealed.........(description of materials and technology)

RVG control: the root canal is obturated uniformly and tightly along its entire length to the physiological opening, temporary dressing.

Third visit:

no complaints

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment: ..(description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

10).Chronic granulomatous periodontitis.

Complaints: The presence of a carious cavity in.... (tooth formula) food ingress.

Objectively: on (name) surface... (tooth formula), deep carious

cavity communicating with the cavity of the tooth. Probing is painless. Percussion is negative. There is no pain from temperature stimuli.

RVG: Widening of the periodontal fissure, in the area of the apex.... (which

root) focus of destruction with clear contours with a diameter of .. (mm)

Treatment: Under application anesthesia......(name) and infiltration (conduction)....(name) the tooth cavity is opened. Evacuation of contents from the root canal. The root canals are mechanically and medicinally treated. Length (mm)....ISO.temporary bandage.

Second visit:

no complaints.

Objectively: The temporary dressing has been preserved. Percussion is negative.

Treatment: Under topical anesthesia (name) and

infiltration (conduction) anesthesia (name) removal of the temporary dressing. Medical treatment of Root Canals. Root

The canals are sealed (description of materials and technology).

RVG control. The root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary dressing.

Third visit:

no complaints

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment: .....(description of manipulations: pin, gasket, filling, restoration, tab indicating materials and color)

Average caries

complaints : for the presence of a carious cavity in the area…………… quickly passing pain from chemical irritants.

Sf/ loc . : in the area of …………… there is a carious cavity of medium depth with softened pigmented dentin, probing the enamel-dentin border is painful.

Deep caries

complaints :: for the presence of a carious cavity in the area of ……………, pain from chemical and thermal irritants, quickly disappearing after removal of the irritant.

Sf/1os.: in the area of …………… there is a deep carious cavity with softened pigmented dentin, probing is painful in the area of the bottom of the carious cavity, the reaction to thermal stimulation is positive and passes quickly.

Chronic pulpitis

complaints : for the presence of a carious cavity in the area of ……………, pain from thermal irritants and when food gets into the carious cavity.

Sf/1os.: In the area of …………… there is a deep carious cavity filled with softened pigmented dentin, probing is painful in the area of the bottom of the carious cavity. Probing revealed an exposed pulp horn. The reaction to thermal stimuli is positive.

Exacerbation of chronic pulpitis

complaints : for spontaneous paroxysmal, night pain with irradiation to the area ……………. From the anamnesis: previously there were pains of a spontaneous nature.

Sf/1os.: .: In the area …………… there is a deep carious cavity communicating with the tooth cavity. probing is sharply painful. The reaction to thermal stimuli is positive, the color of the tooth is not changed.

Chronic fibrous periodontitis is noted

complaints : for the presence of a deep carious cavity in the area…………… From the anamnesis: occasionally it is characterized by slight pain when biting.

Sf/1os.: In the area…………… there is a deep carious cavity communicating with the tooth cavity. probing the entrance to the cavity is painless, percussion is painless. the tooth is discolored. On Rg: widening of the periodontal fissure in the area of the root apex.

Chronic granulomatous periodontitis

complaints : for the presence of a deep carious cavity in the area …………… Change in tooth color. From the anamnesis: occasionally there is sensitivity in the jaw and slight pain when biting.

Sf/1os.: In the area: …………… deep carious cavity communicating with the tooth cavity. Probing the entrance to the cavity is not painful. On palpation on the gum c

There is a painful desiccation of the vestibular surface. Percussion lightly

painful. On Rg: in the area of the root apex there are clearly defined, round-shaped bone tissue depressions of size …….

Chronic granulating periodontitis

complaints : for the presence of a deep carious cavity in the area of ……………. The history shows occasional pain when biting, periodic formation of a fistula in the area……..

Sf/1os.: In the area……………a deep carious cavity communicating with the tooth cavity. The tooth is discolored. Probing is painless. Percussion is slightly painful. On the mucous membrane in the area………… there is a fistulous tract with purulent compartments. On Rg: in the area of the root apex there is a focus of destruction of bone tissue with corroded contours.

Exacerbation of chronic periodontitis

complaints : for aching pain in the area……………Sharp pain when biting on a tooth.

Sf/1os.: .: In the area …………… there is a deep carious cavity communicating with the tooth cavity. probing is painless. Percussion is sharply painful. Mucous in

area…………… hyperemic, slightly swollen. Rg according to the form.

Since the creation of the modern structure of dental care, the medical record of a dental patient has been its basic element. It existed when there was no trace of other documents, without which it is impossible to imagine the work of a modern clinic (contract, protocol of voluntary informed consent, insurance policy, etc.).

At the same time, many dental clinics completely or partially ignore the role of the dental patient’s medical record: they either do not use it at all, or they modernize, modify, or invent their own versions. And if the use of various variations on the theme of a dental patient’s medical record can be understood (in many ways, the existing form already lags behind the requirements of the time), then the complete absence of a medical record is completely unacceptable.

What is a dental patient's medical record?

A medical record of a dental patient is a document that properly identifies the patient and contains information characterizing the characteristics of the condition and changes in the state of his health, established by the doctor and confirmed by laboratory, instrumental and instrumental research, as well as the stages and features of the treatment.

Registration of a medical card for a dental patient –

The medical record of a dental patient is drawn up in accordance with orders of the USSR Ministry of Health No. 1030 of October 4, 1980 and No. 1338 of December 31, 1987. At the same time, the Ministries of Health of the USSR and the Russian Federation managed to create extreme confusion with the medical record. In 1988, an order of the USSR Ministry of Health was issued (No. 750 dated 10/05/1988), according to which the Order of the Ministry of Health No. 1030 became invalid. However, another, newer Ministry of Health, now the Russian Federation, since 1993 began to regularly refer to the provisions of Order No. 1030 of the USSR Ministry of Health, introducing appropriate changes and additions to it.

There are no later basic orders or other acts of the Russian Ministry of Health establishing the form of a medical record. Therefore, although many provisions of Order No. 1030 have lost force, new regulatory documents periodically contain references to those parts of the order that relate to the maintenance of medical records. In particular, the requirement remains that all medical institutions (note, regardless of their form of ownership) are required to maintain medical records in the established form. In dentistry, this is Form No. 043/у “Medical record of a dental patient.”

What does a medical card include?

Medical record No. 043/u contains three main sections.

1) First section– passport part. It includes:

card number;
date of its registration;
last name, first name and patronymic of the patient;
patient's age;
patient's gender;
address (place of registration and place of permanent residence);
profession;
diagnosis at initial visit;
information about past and concomitant diseases;
information about the development of the present (which became the reason for the initial treatment) disease.

This section can be supplemented with passport data (series, number, date and place of issue) for persons over 14 years of age, and birth certificate data for persons under 14 years of age.

2) Second section– objective research data. He contains:

external inspection data;
oral examination data and a table of dental condition, filled out using officially accepted abbreviations (absent - O, root - R, caries - C, pulpitis - P, periodontitis - Pt, filled - P, periodontal disease - A, mobility - I, II, III (degree), crown - K, artificial tooth - I);
description of bite;
description of the condition of the oral mucosa, gums, alveolar processes and palate;
X-ray and laboratory data.

3) Third section- a common part. It consists of:

examination plan;
treatment plan;
treatment features;
records of consultations, consultations;
clarified formulations of clinical diagnoses, etc.

Some features of the medical record

The material and type of medical record of a dental patient does not matter much. It can be produced in a clinical setting or by printing and, as a rule, is an A5 notebook. The main requirement is that it be in paper form and have records in the form approved by law. The passport part is prepared by a medical registrar, clinic administrator or nurse.

All other entries in the medical record are made only by the doctor, legibly, without corrections (a printed (computerized) option for making entries is possible), using only generally accepted abbreviations. The formulations of diagnoses, anatomical formations, names of instruments and medications are indicated in full, without abbreviations, taking into account the officially used terminology. The entry made is confirmed by the signature and personal seal of the doctor.

In addition to the records, the following must be included (pasted) in the medical record:

test results (if any) - originals or copies;
extracts from other medical institutions where dental care was provided, especially if the provision of dental care in other institutions occurred after the patient first applied (began to be observed) in this dental clinic;
medical reports, expert opinions, consultations received in connection with the diseases for which the patient is observed in this clinic;
medical reports, expert opinions, consultations received in connection with other diseases, the course of which may affect the characteristics of the dental disease;
information on cancer examinations (based on the order of the Ministry of Health of the Russian Federation “On measures to improve the organization of cancer care for the population of the Russian Federation” No. 270 dated September 12, 1997);
information on radiation doses received by the patient during X-ray examinations (based on the order of the Ministry of Health of the Russian Federation “On the introduction of state statistical monitoring of radiation doses of personnel and the population” No. 466 of December 31, 1999);
X-rays of the patient’s teeth and maxillofacial area, taken in this dental clinic.

Let's take a closer look at the last point. Of the entire evidence base that is used by the parties when considering consumer claims in court in connection with the quality of services provided, X-ray images are of the greatest importance. Why? As an example, let’s look at a controversial situation that arises most often.

The patient had his teeth treated in several clinics and collected his x-rays from everywhere after the treatment was completed. At the same time, of course, in all clinics there were certain documents confirming the fact of treatment (service agreements, entries in the medical record, payment receipts, checks, etc.). In one of the clinics, an instrument broke off in a tooth canal during treatment. However, the patient sued not the clinic where the instrument was broken, but the richest of those where he was treated.

At the same time, it is almost impossible to prove the absence of fault of the clinic specified in the claim if the clinic cannot present an x-ray taken after completion of treatment. That is why the clinic is extremely interested in keeping all the images taken on the patient. However, certain legal difficulties arise here.

The fact is that radiography is usually included by clinics in the price list as a separate type of service. And on the basis of the Civil Code of the Russian Federation and the Law “On the Protection of Consumer Rights”, the patient has the right to regard the x-ray performed as a service paid for by him, the material expression (result) of which is an x-ray. Accordingly, the patient acquires the full right to take this image for himself.

Of course, this situation does not suit the clinic at all. Therefore, the clinic usually uses the following exit options:

include in the Contract for the provision of dental services a clause according to which x-rays taken in the clinic are an integral part of the medical record of the dental patient. In this case, all images taken at the clinic remain its property on the basis of an agreement concluded with the patient.
They give the patient not the image itself, but its image on paper or other media - for example, a copy from a visiograph, or a printout of a scanned image.

However, all of the above applies to the medical record of a dental patient, form No. 043/u. If a dental clinic uses its own form of medical records, then it may face serious problems in court proceedings. The fact is that the patient can submit a request for the clinic to provide evidence of a medical record of a dental patient in the form established by law (form No. 043/u).

In this case, the provision of a medical card of a different form by the dental clinic may be interpreted by the court as a formal basis for recognizing this form as not meeting the requirements of the law, and on this basis the card may not be accepted as written evidence. And this will allow you to ignore all the entries made in the card and give the patient grounds to accuse the clinic of improper record keeping.

Since this form of card is truly outdated and does not fully reflect both changes in civil legislation and new diagnostic and treatment standards, its certain modernization becomes inevitable. Therefore, in dentistry, as a way out of this situation, they use a loose leaf for the medical record (information sheet), taking into account the specific features of a particular clinic. It is much worse for a dental clinic if the dental patient’s medical record is not maintained at all.

FAQ -

Who makes entries in the medical record?
The passport part is filled out by the registrar, administrator or nurse; all other entries are made only by the doctor.
How are entries entered into the medical record?
Legibly, using only generally accepted abbreviations, without corrections, handwritten or printed, certified by signature and the doctor’s personal seal.
Why do you need a medical card?
To reasonably protect the interests of the dental clinic, first of all, in court.
Can dentistry issue a medical card to a patient?
Formally yes, in fact no.
What problems can there be for using the wrong card options?
An incorrect version of the map may not be recognized by the court as written evidence, and the resulting lack of documentation required by law may become the reason for legal claims.
Does the patient have the right to collect x-rays?
Yes, at least copies of photographs on paper or other media.
How do dentists update medical records?
Use the medical record insert – information sheet.