Functions of a medical card in dentistry. Recommendations for students on filling out a medical record of a dental patient with defects in hard dental tissues. V. Designations of various types of dental lesions
The current form 043 y was developed, approved and put into circulation on October 4, 1980. The body that approved the document is the USSR Ministry of Health. The form is used by outpatient dental institutions as the main accounting document for recording patient data and the course of treatment.
A dental patient card form 043 y is issued to all citizens who have applied for help. The document exists in one copy for each patient. The number of specialists involved in the treatment of the patient does not matter. All data is summarized in one card.
Card form 043 y is produced in A5 format. This is a notebook that includes a title page and pages with ready-made columns for entering data. The form includes a contract for the provision of dental services, which must be signed by the patient after reading the text of the contract. The title page must contain the exact full name of the institution. Each card has its own unique individual number.
The dental patient card form 043 y must contain the patient's passport data. This sheet is filled out at the register. The basis is the documents proving the identity of the applicant. The patient enters information about his health into the card.
Information about the state of health should include such important parameters as the presence of allergies, blood type and Rh factor, chronic diseases of internal organs, existing head injuries, medications currently taken, and so on. It is very important to include as much information as possible. This will help the specialist choose the safest and most effective treatment.
Diagnosis of diseases of the teeth and oral cavity may include both a visual examination and x-ray studies. The use of an x-ray machine involves irradiation of the patient. The received dose of radiation must also be recorded in the card.
Pages with the results of the examination, data on the diagnosis and the course of treatment are filled in by specialists who carry out the corresponding procedures. The patient must document their consent to the examination and treatment plan.
An important feature of filling out the form is the ability to record the names of drugs in Latin. The rest of the information is entered only in Russian. Handwritten text must be legible. Corrections are confirmed by signature.
Medical card 043 y is the property of the clinic.
According to the instructions, the dental card form 043 is not handed out. This legal document can be used in the event of litigation and claims from the patient. The card is stored in an outpatient dental facility for 5 years. After this period, the form is transferred to the archive of the organization. The period of storage in the archive is 75 years.
Unlike most established forms of medical forms, form 043 y is advisory. The form can be supplemented and adjusted to the needs of a particular medical institution. It is possible to order such an adjustment of the form in the City Blank printing house, taking into account all the requirements of the customer.
The document can be reduced, supplemented, correct columns. To preserve the protective functions of the document, it is recommended not to exclude important items of the form, for example, an agreement on consent to the provision of services, data on the primary diagnosis. The completeness of the data confirms the quality of the services provided.
You can buy a medical card of a dental patient both in a single copy and in a batch of the required volume. For institutions in Moscow and the Moscow region, delivery by courier is possible. Non-standard forms are printed after final approval.
AT THE DEPARTMENT OF ORTHOPEDIC DENTISTRY
Medical card of a dental patient
The main document for recording the work of a dentist of any specialty is a medical record of a dental patient form 043-y, approved by order of the Ministry of Health of the USSR No. 1030 dated 04.10.1980.
A medical card (outpatient card or medical history) is a mandatory document of a medical outpatient appointment that performs the following functions:
is a plan for a thorough examination of the patient;
registers the data of the anamnesis, clinical and paraclinical methods of examination of the patient, reflecting the state of the organs and tissues of his oral cavity;
fixes the plan and stages of treatment, changes that have occurred 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 that is considered in various conflict situations, including in the courts.
A medical card of the approved form is issued, as a rule, in a typographical way. Currently, clinics practice the use of a formalized computer version of an outpatient card, but with the condition of mandatory duplication on paper.
Medical record (account form 043-y) includes:
passport part, which is filled in the registry when the patient first visits the clinic;
medical unit, which is filled directly by the doctor and includes:
- 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; related dental; concomitant somatic);
- treatment plan, including, if necessary, preparatory measures (sanation and special) and the actual methods of orthopedic treatment;
- treatment diary.
Writing a case history of patients in an orthopedic dentistry clinic should be based on consistent, sufficiently detailed, competent and accurate filling of all columns of an outpatient dental patient card so that anyone reading it can understand the contents of the records.
Features of writing a medical history of patients
with defects in hard tissues of teeth
^ RATIONALE FOR THE DIAGNOSIS
SURVEY
with defects in the hard tissues of the anterior group of teeth - aesthetic problems caused by congenital or acquired defects in the surface and color of the tissues of the teeth, a change in their shape or position in the dentition, destruction or complete absence of the crown part, etc .;
with the destruction of the crowns of the chewing group of teeth - a violation of the function of chewing;
with a significant destruction of a large number of teeth - a change in appearance (changes in the proportions of the face), pain in the temporomandibular joint;
in some cases - increased sensitivity of the teeth (for example, with increased abrasion of hard tissues of the teeth, with wedge-shaped defects).
Count "Transferred and concomitant diseases" - data are entered on general somatic pathology: diseases of the cardiovascular system, gastrointestinal tract, endocrine pathology, infectious diseases, etc. The listed pathological conditions can affect the choice of materials for the manufacture of prostheses, the timing of the start of prosthetics, the stages of the planned treatment, the choice of anesthetics during the preparation of teeth. So, for anesthesia in patients with pathology of the cardiovascular system, the anesthetic should not contain adrenaline.
Count "Allergological History" the patient is asked if there were any allergic reactions to medications, household chemicals, food products, etc., whether anesthesia was previously used, and whether any complications were noted after it was performed.
To diagnose the pathological condition of the dentoalveolar system, a study should be carried out in the most thorough way. patient's dental status followed by a detailed description of it in the medical record.
In concept "dental status" includes data from an external examination of the patient and an examination of his oral cavity.
When describing the results of an external examination, special attention should be paid to:
signs of a change in proportions - a decrease in the height of the lower part of the face, which may be due to the 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 (which is determined by palpation).
When describing the results of the 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). The teeth are numbered from the midline. The first number indicates the quadrant (segment) of the jaw, the second - the corresponding tooth.
^ Example:
P with 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 conventions, all teeth are marked ( ^ P- sealed; WITH- with carious cavities, R- with a significantly or completely destroyed crown part); degree of tooth mobility 1, P, W, 1U), teeth with orthopedic constructions ( TO- artificial crowns ShtZ- pin tooth), etc.
Under the dental formula, additional data are recorded regarding the teeth to be restored by orthopedic methods: the degree of destruction of the crown 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. Separately, the state of the marginal periodontium is described, in particular, changes in the gingival margin (inflammation, recession), the presence of a gingival pocket, its depth, the ratio of the extra- and intra-alveolar parts of the tooth.
Example:
16 - there is a filling on the chewing surface, the marginal fit 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, marginal gum without signs of inflammation, tightly covers the neck of the tooth.
11 - artificial metal-plastic crown, plastic lining is changed in color, there is hyperemia of the marginal edge of the gums.
21 - the coronal part is changed in color, the medial angle of the cutting edge is chipped, the tooth is stable, located in the dental arch, percussion is painless.
26, 27, 37, 36 - artificial all-metal crowns in a satisfactory condition, tightly cover the necks of the teeth, marginal gums without signs of inflammation.
31, 32, 41, 42 - dental deposits, slight hyperemia of the gingival margin.
45 - on the occlusal surface, the filling 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, when probing, a violation of the marginal fit is determined, a chip of the medial lingual tubercle, the tooth is stable, percussion is painless.
In the graph "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 extension of the 46th tooth relative to the occlusal surface by 1.5 mm (or ¼ of the crown height). There is hypertrophy of the alveolar process in area 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:
the state of the crown - the presence of a carious cavity, fillings, the ratio of the bottom of the carious cavity to the tooth cavity;
characteristics of the tooth cavity - the presence of a shadow of filling material, instruments, denticles;
the state of the roots: quantity, shape, size, contours;
characteristics of root canals: width, direction, degree and quality of filling;
assessment of the periodontal gap: uniformity, width;
the state of the compact plate of the hole: preserved, destroyed, thinned, thickened;
the state of the periapical tissues, analysis of the pathological shadow, determination of its localization, shape, size and nature of the contour;
assessment of the surrounding tissues: the state of the interdental septa - height, the state of the end compact plate.
^ Example:
On intraoral x-rays of satisfactory quality:
16 - a change in the position of the tooth relative to the adjacent ones is determined (advancement by 1.5 mm in relation to the occlusal surface), in the crown part of the tooth - 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 - the absence of the coronal part, in the root canal, throughout the entire length of the canal to the root apex, 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 region 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 the metal wire pin is traced. In the apical third of the root canal, the shadow of the filling material is not determined. Uniform expansion of the periodontal gap. In the region of the root apex, there is a focus of rarefaction of bone tissue with fuzzy contours in the form of "tongues of flame".
21 – a chip of the medial angle of the cutting edge of the coronal part, in the root canal there is an intense shadow of the filling material with filling defects. No changes were found in the periapical tissues.
46 - in the area of the tooth crown, the shadow of the filling material is close to the cavity of the tooth, the marginal fit of the filling is broken, the root canals are free from the filling material. There are no changes in the periapical tissues.
32, 31, 41, 42 – pathology of hard tissues was not revealed, interdental septa are reduced to 1/3 of the length of the roots, there is a lack of end compact plates, the tops have a "scalloped" appearance.
The same column describes the data of electroodontodiagnostics and other examination methods (for example, the results of tomography of the temporomandibular joints in patients with signs of a decreasing bite).
Based on the data of the clinical examination and the results of additional research methods, a diagnosis . Accordingly, graph "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 dentition and complication of the underlying disease;
concomitant dental diseases;
common comorbidities.
The main diagnosis should be detailed, descriptive and comply with the international classification of nosological forms of dental diseases based on the ICD -10 C.
When formulating the main diagnosis, first of all, morphological changes in the dentition are distinguished, indicating the etiological factor (for example, partial defect of the crown part of the 46th tooth of carious origin).
In some cases, the underlying disease (in the example partial defect of the crown part of the 46 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 elongation of the 1st degree of the P-a form in the region 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 crown part of the 13th tooth of carious origin (IROPZ more than 0.8). Functional and aesthetic insufficiency of the artificial crown of the 12th tooth. Partial defect with a change in the color of hard tissues of the 21st tooth of traumatic origin Partial defect of the crown 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 the P-a form in the area of the 16th tooth.
The second component of the main diagnosis is functional part, characterizing dysfunctions, movements of the lower jaw. For example, "Aesthetic insufficiency of the dentition of the upper jaw", « Functional insufficiency of the dentition of the lower jaw», "Blocking movements of the lower jaw."
In the above example, the full wording main diagnosis as follows:
“Complete defect of the crown part of the 13th tooth of carious origin (IROPZ more than 0.8). Functional and aesthetic insufficiency of the artificial crown of the 12th tooth. Partial defect with a change in the color of hard tissues of the 21st tooth of traumatic origin Partial defect of the crown part of the 46th tooth of carious origin, complicated by deformation of the occlusal surface of the dentition of the upper jaw - - dentoalveolar elongation of the 1st degree of the U-shape in the area of the 16th tooth. Functional and aesthetic insufficiency of the dentition, blocking of the movements of the lower jaw in the anterior occlusion.
IN concomitant dental diagnosis all identified dental pathology is taken out, which will be treated by dentists, 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 there are somatic diseases of the cardiovascular, endocrine, nervous systems, respiratory organs, gastrointestinal tract, etc.
Depending on the formulation of the diagnosis, 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 concomitant 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 referred for oral cavity sanitation before prosthetics: treatment of teeth 14, 17, removal of dental deposits, treatment of gingivitis. Professional oral hygiene recommended.
Special preparation of teeth is carried out according to prosthetic indications and is necessary for more effective orthopedic treatment and to exclude the possibility of complications after treatment.
Before orthopedic treatment of defects in hard tissues of teeth, more often than others, special therapeutic measures preparation of teeth, among which it should be noted:
root canal refilling;
depulpation of teeth planned for orthopedic construction (for example, if radical preparation of teeth with a wide cavity is necessary, with inclinations 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 design of dentures should be indicated, with the help of which the goal of orthopedic treatment will be realized.
^ Example:
"Restore the anatomical shape of the coronal part
tooth 16 – cast all-metal crown;
teeth 13, 11 – ceramic-metal crowns on cast stump
pin tabs;
tooth 21 – ceramic-metal crown;
tooth 46 – cast all-metal crown on a cast stump pin tab.
If it is necessary to carry out special preparation of the tooth for prosthetics, the planned activities should also be detailed in the column "Treatment plan".
Example:
In order to eliminate the deformation of the occlusal surface of the dentition of the upper jaw, it is recommended to depulp the 16th tooth, followed by its grinding (shortening) and restoring its shape with a cast all-metal crown.
Restore the anatomical shape of the crown of the 13th tooth with a cast stump pin tab and a ceramic-metal crown with preliminary preparation of the root canal for a cast stump pin tab (by 2/3 of the length unsealing).
Restore the anatomical shape of the crown part of the 11th tooth with a cast stump pin tab and a ceramic-metal crown with a preliminary revision, refilling and preparation of the root canal for a cast stump pin tab.
To restore the anatomical shape of the crown part of the 21st tooth with a metal-ceramic crown with a preliminary refilling of the root canal using a fiberglass pin.
To restore the anatomical shape of the crown of the 46th tooth with a cast stump pin tab and a cast all-metal crown with preliminary depulpation of the tooth and preparation of channels for a cast stump pin tab.
The patient should be informed by the doctor about all possible options for dental prosthetics and the most optimal method of treatment in this 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) of the following wording: “ I am familiar with the options for prosthetics, I agree with the plan for prosthetics (including the plan for preparing for prosthetics).
In chapter "Diary » describes the clinical stages of orthopedic treatment, indicating the date of admission of the patient and the date of the next appointment. We give examples of filling "Diary" depending on the design of the denture in the orthopedic treatment of defects in the hard tissues of the teeth.
| date | Diary | Surname of the attending physician | |
| ^ Orthopedic treatment using a metal stamped crown | |||
| 27.02.09 | Preparation of the 27th tooth for a metal stamped crown. Obtaining a working two-phase impression with a silicone impression material (for example, Speedex) and an auxiliary impression from the lower jaw with an alginate impression mass (for example, Cromopan). Turnout 01.03.09. | Signature | |
| 01.03.09 | Fitting a metal stamped crown for 27 teeth. There are no comments. Turnout 02.03.09 | Signature | |
| 02.03.09 | Final fitting and fixation of a metal stamped crown on the 27th tooth with phosphate cement (for example, Unicem). Recommendations are given. | Signature | |
| ^ Orthopedic treatment with a plastic crown | |||
| 27.02.09 | Preparation of 21 teeth for a plastic crown. Obtaining a working two-phase impression with a silicone impression material (for example, Speedex Cromopan) from the lower jaw. The choice of plastic color according to the Sinma plastic color scale (for example, color No. 14). Turnout 01.03.09 | Signature | |
| 01.03.09 | Fitting a plastic crown with correction of occlusal relations and fixing it on the 21st tooth 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, tooth 11 was prepared for a metal stamped crown. Taking a two-phase impression with a silicone impression material (e.g. Speedex) from the upper jaw and an auxiliary impression with an alginate impression mass (for example, Cromopan) from the lower jaw. Turnout 01.03.09 | Signature | |
| 01.03.09 | Fitting of a metal stamped crown for 11 teeth. Under infiltration anesthesia with 0.7 ml of a 4% solution of articaine with epinephrine, an additional preparation of the cutting edge of the vestibular and proximal surfaces of the 11th tooth was performed. Obtaining an impression 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 a silicone impression mass (for example, Speedex). Choice of the color of the plastic cladding according to the Sinma plastic color scale (eg color no. 14 + 19). Turnout 03.03.09. | Signature | |
| 03.03.09 | Final fitting of the metal-plastic crown and its fixation 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 conduction anesthesia with 1.0 ml of a 4% solution of articaine with epinephrine, tooth 37 was prepared for a cast all-metal crown. Retraction of the gums by mechanochemical method using a retraction thread impregnated with epinephrine. Obtaining a working two-phase impression with a silicone impression mass (for example, Speedex) from the upper jaw and an auxiliary impression with an alginate impression mass (for example, Cromopan) from the lower jaw. Turnout 04.03.09. | Signature | |
| 04.03.09 | Checking the quality of a cast all-metal crown, fitting it on the stump of the 37th tooth with correction of occlusal relations in the central, anterior and lateral occlusions. There are no comments. Turnout 06.03.09. | Signature | |
| 06.03.09 | The final fitting of a cast all-metal crown and its fixation on the 37th tooth with glass ionomer cement (for example, Fuji). Recommendations are given. | Signature | |
| ^ Orthopedic treatment with metal-ceramic crowns | |||
| 27.02.09 | Under infiltration anesthesia with 1.3 ml of a 4% solution of articaine with epinephrine, 11, 21 teeth were prepared for metal-ceramic crowns. Gingival retraction with impregnated retraction cords. Obtaining a working two-phase impression with a silicone impression mass (for example, Speedex) from the upper jaw and an auxiliary impression with an alginate impression mass (for example, Cromopan) from the lower jaw. Fitting and fixation of standard temporary provisional crowns on the stump of 11, 12 teeth with water dentin. Turnout 04.03.09. | Signature | |
| 04.03.09 | Fitting of cast metal caps on supporting teeth 11, 21. Choosing 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 dentin. Turnout 06.03.09. | Signature | |
| 06.03.09 | Checking the design and fitting metal-ceramic crowns for 11, 21 teeth. Correction of occlusal ratios in the central, anterior and lateral occlusions. There are no comments. Fixation of temporary provisional crowns on the stump of 11, 12 teeth with water dentin. Turnout 07.03.09. | ||
| 07.03.09 | Final fitting and fixation of metal-ceramic crowns on the supporting 11, 21 teeth with glass ionomer cement (for example, fuji). Recommendations are given. | ||
| ^ Orthopedic treatment with the use of an artificial crown on a cast stump pin inlay made by a direct method | |||
| 27.02.09 | Preparation of the stump of the 13th tooth. Root canal preparation. Waxing of a pin tab Lavax. Temporary filling from water dentin. Turnout 04.03.09. | Signature | |
| 04.03.09 | Fitting and fixation of a cast stump pin tab in the root canal of the 13th tooth with phosphate cement (for example, Uniface). Turnout 05.03.09. | Signature | |
| 05.03.09 | Additional preparation of the stump of the 13th tooth. Gingival retraction with epinephrine impregnated retraction cord. Obtaining a working two-phase impression with a silicone impression mass (for example, Speedex) from the upper jaw and an auxiliary impression with an alginate impression mass (for example, Cromopan) from the lower jaw for the manufacture of a metal-ceramic crown for the 13th tooth. Fitting and fixation of a standard temporary provisional crown on the stump of the 13th tooth with water dentin. Turnout 09.03.09. | Signature | |
| 09.03.09 | Checking the design and fitting of a cast metal cap on the stump of the 13th tooth. Choosing 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 dentin. Turnout 12.03.09. | ||
| 12.03.09 | Checking the design and fitting of a metal-ceramic crown for 13 teeth. Correction of occlusal relations in the central, anterior and lateral occlusions. There are no comments. Fixation of a temporary provisional crown on the stump of the 13th tooth with water dentin. Turnout 13.03.09. | ||
| 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 with the use of an artificial crown on an indirectly cast stump pin tab | |||
| 27.02.09 | Preparation of the stump of the 26th tooth. Preparation of root canals. The introduction of a corrective silicone impression mass (for example, Speedex) into the root canals using a canal filler. Obtaining a two-phase impression with root canal imprints with silicone impression masses Speedex. Temporary filling from water dentin. Turnout 04.03.09. | Signature | |
| 04.03.09 | Fitting a collapsible stump pin tab with a sliding pin in the root canals of the 26th tooth, fixing it with glass ionomer cement (for example, fuji). Turnout 05.03.09. | Signature | |
| 05.03.09 | Additional preparation of the stump of the 26th tooth. Gingival retraction with impregnated retraction cord. Obtaining a working two-phase impression from the upper jaw with a silicone impression material (for example, Speedex), auxiliary - with a lower alginate impression mass (for example, orthoprint) for the manufacture of a cast all-metal crown on the stump of the 26th tooth. Turnout 06.03.09. | Signature | |
| 09.03.09 | Checking the design and fitting of a cast all-metal crown on the stump of the 26th tooth. Correction of occlusal relations. There are no comments. Turnout 07.03.09. | ||
| 11.03.09 | Final fitting and fixation of a cast all-metal crown on an artificial stump of the 26th tooth with glass ionomer cement (for example, fuji). Recommendations are given. | ||
The final section of the medical history of the dental patient "Epicrisis" filled in according to a certain scheme:
Patient (full name) 27.02.09 applied to the clinic of orthopedic dentistry with complaints about _______________________________________.
Based on the examination data, the following diagnosis was made: _________________________________________________________________.
Orthopedic treatment performed _____________________________
____________________________________________________________
The anatomical shape of the crowns of the teeth, the integrity of the dentition of the upper jaw, the lost functions and the aesthetic norm were restored.
The medical history is completed by the signature of the doctor and, preferably, the head of the department.
OPTIONS FOR RECORDING THE HISTORY OF PATIENTS WHO ARE INDICATED FOR TOOTH EXTRACTION AND OTHER ORTHOPEDIC MANIPULATIONS
Exacerbation of chronic periodontitis
Example 1local changes. On external examination, there is no change. Submandibular lymph nodes are slightly enlarged on the left, painless on palpation. The mouth opens freely. In the oral cavity: under a filling, changed in color, its percussion is painful. In the area of the tops of the roots 27, a slight swelling of the gingival mucosa is determined from the vestibular side, palpation of this area is slightly painful. On radiograph 27, the palatine root was sealed up to the apex, the buccal roots - 1/2 of their length. At the apex of the anterior buccal root there is a rarefaction of bone tissue with fuzzy contours.
Diagnosis: "exacerbation of chronic periodontitis 27 tooth".
a) Under tuberal and palatine anesthesia with 2% novocaine solution - 5 mm or 1% trimecanne solution - 5 mm plus 0.1% adrenaline hydrochloride - 2 drops (or without it) extraction was performed (specify the tooth), curettage of the hole ; hole filled with blood clot.
b) Under infiltration and palatine anesthesia (anesthetics, see entry above, indicate the presence of adrenaline), the removal of ( 8 7 6 | 6 7 8 ), curettage of the hole; hole filled with blood clot.
c) Under infiltration and palatine anesthesia (anesthetics, see entry above, indicate the presence of adrenaline), the removal of ( 5 4 | 4 5 ). Curettage of the hole (holes), the hole (s) filled (were) with a blood clot (s).
d) Under infraorbital and palatine anesthesia (anesthetics see above, indicate the presence of adrenaline) (5 4 | 4 5).
e) Under infiltration and incisive anesthesia (anesthetics see above, indicate the presence of adrenaline) 3 2 1 | 1 2 3. Curettage of the hole, it is compressed and filled with a blood clot.
f) Under infraorbital and incisive anesthesia (anesthetics see above, indicate the presence of adrenaline), the removal of ( 3 2 1 | 1 2 3
). Curettage of the hole, it is compressed and filled with a blood clot.
Acute purulent periodontitis
Example 2Complaints of pain in the area of 32, radiating to the ear, pain when biting on 32, a feeling of a "grown" tooth. The general condition is satisfactory; past illnesses: pneumonia, childhood infections.
History of the disease. About a year ago, for the first time, pain appeared at 32, it was especially disturbing at night. The patient did not go to the doctor; gradually the pain subsided. 32 days ago, pain reappeared; went to the doctor.
local changes. On external examination, there are no changes. The submental lymph nodes are slightly enlarged, painless on palpation. The mouth opens freely. In the oral cavity 32 - there is a deep carious cavity communicating with the tooth cavity, it is mobile, percussion is painful. The mucous membrane of the gums in area 32 is slightly hyperemic, edematous. There are no changes on the radiograph 32.
Diagnosis: "acute purulent periodontitis 32".
a) Under mandibular and infiltration anesthesia (anesthetics see above, indicate the presence of adrenaline), an extraction was performed (indicate a tooth) 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38; curettage of the holes, they are compressed and filled with blood clots.
b) Under torusal anesthesia (anesthetics see above, indicate the presence of adrenaline), 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38 were removed.
Curettage of the hole, it is compressed and filled with a blood clot.
c) Under bilateral mandibular anesthesia (anesthetics see above), removal of 42, 41, 31, 32 was performed. Curettage of the hole, it was compressed and filled with a blood clot.
d) Under infiltration anesthesia (anesthetics, see above, indicate the presence of adrenaline), 43, 42, 41, 31, 32, 33 were removed. Curettage of the hole, it was compressed and filled with a blood clot.
Acute purulent periostitis
Example 3Complaints of swelling of the cheek on the right, pain in this area, fever.
Past and concomitant diseases: duodenal ulcer, colitis.
History of the disease. Five days ago there was pain in 3 |; Two days later, a swelling appeared in the gum area, and then in the buccal area. The patient did not go to the doctor, applied a heating pad to his cheek, did warm intraoral soda baths, took analgesics, but the pain grew, the swelling increased, and the patient went to the doctor.
local changes. During external examination, a violation of the configuration of the face is determined due to swelling in the buccal and infraorbital regions on the right. The skin above it is not changed in color, painlessly gathers into a fold. The submandibular lymph nodes on the right are enlarged, compacted, slightly painful on palpation. The mouth opens freely. In the oral cavity: 3 | - the crown is destroyed, its percussion is moderately painful, mobility II - III degree. Pus exudes from under the gum margin Transitional fold in the area 4 3 2| swells significantly, painful on palpation, fluctuation is determined.
Diagnosis: "acute purulent periostitis of the upper jaw on the right in the area 4 3 2| »
Example 4
Complaints of swelling of the lower lip and chin, extending to the upper part of the chin area; sharp pains in the anterior part of the lower jaw, general weakness, lack of appetite; body temperature 37.6 ºС.
History of the disease. After hypothermia a week ago, spontaneous pain appeared in the previously treated 41, pain when biting. On the third day from the onset of the disease, the pain in the tooth decreased significantly, but swelling of the soft tissues of the lower lip appeared, which gradually increased. The patient did not carry out treatment, he turned to the clinic on the 4th day of the disease.
Past and concomitant diseases: influenza, tonsillitis, intolerance to penicillin.
local changes. During external examination, swelling of the lower lip and chin is determined, its soft tissues are not changed in color, they fold freely. The submental lymph nodes are slightly enlarged, slightly painful on palpation. Opening the mouth is not difficult. In the oral cavity: the transitional fold in the region of 42, 41, 31, 32, 33 is smoothed, its mucous membrane is edematous and hyperemic. On palpation, a painful infiltrate in this area and a positive symptom of fluctuation are determined. Crown 41 is partially destroyed, its percussion is slightly painful, I degree mobility. Percussion 42, 41, 31, 32, 33 painless.
Diagnosis: "acute purulent periostitis of the lower jaw in the area of 42, 41, 31, 32".
Recording of orthopedic intervention for acute purulent periostitis of the jaws
Under infiltration (or conduction - in this case, specify which one) anesthesia (anesthetic see above, indicate the presence of adrenaline), an incision was made along the transitional fold in the region of 43,42,41.
(indicate the formula of the teeth) 3 cm (2 cm) long to the bone. Got pus. The wound was drained with a rubber strip. Assigned (indicate the medications prescribed to the patient, their dosage).
The patient is disabled from _______ to _________, sick leave No. ______ issued. Appearance ______ for dressing.
A medical card is a mandatory document for every medical institution. It summarizes information about the client's health, being an integral part of the clinic's workflow.
Its correct filling guarantees the preservation of information about human health, treatment and its results. The medical card of a dental patient has important features, so you need to know what it is and how it is filled out.
What is it, what distinguishes it from a regular medical card
The outpatient card is a document of the established form, which includes basic information about the client, history, diagnosis and treatment. This is one of the main primary documents in a medical institution, which allows you to systematize information. It also has an important legal significance, which makes it possible to prove the correctness in controversial situations.
An important feature of the dental medical record and its difference is a highly specialized focus - it reflects the state of a person.
Legislative framework: understanding orders
Form 043 / y is fixed by the Order of the Ministry of Health of the USSR No 1030. By a letter dated 11/30/2009 of the Ministry of Health and Social Development of the Russian Federation, this form is recommended for use by dentists. It is the same for both state dental clinics and commercial ones.
Since form 043 / y is approved at the legislative level, it is a reporting document.
Sample form 043/y:
Modifications of form 043 / y are undesirable, since in disputable situations, for example, in a lawsuit, the outpatient card of a dental patient according to the established model will be taken into account as evidence.
If necessary, information tabs are pasted into the card printed according to the established pattern, which supplement the content without changing the form itself.
Content - no encryption
Form 043 / y provides for three parts. The first contains passport information:
- number and date;
- Full name, date of birth of the patient;
- address;
- job title;
- the diagnosis of a dentist;
- chronic diseases.
The second part of the medical record specifies the diagnosis and details of the examination:
- examination by a dentist;
- features of the condition of the teeth;
- bite features;
- laboratory test results and X-ray data.
The third part contains:
- prescriptions and recommendations;
- conclusions of other highly specialized specialists.
Templates for some of the card pages:
Sample Dental Patient Treatment Plan:
This is what a dental examination form looks like:
Who and how to fill in - no one is rejected
Dental card forms exist in electronic form, which can be printed either directly at the clinic or ordered to be printed in a specialized organization. Filling out the outpatient card is carried out by the employees of the clinic.
The passport information in the first part is filled in by the administrator of the dental clinic during the initial contact of the client, or by the nurse during the initial examination of the dental patient.
The second and third parts are directly related to the diagnosis and treatment regimen, the medical history, so only a dentist has the right to fill them out.
As part of the automation of the process, electronic services are created that allow you to save in electronic form data on medical interventions, on dental treatment and response to anesthesia, dates of calls and appointments, and the results of radiographic examinations. Electronic medical dental patient records can be filled out along with paper medical records. If the dental clinic conducts electronic document management, this does not cancel its obligation to fill out the 043 / y form in paper form.
What information is entered, what is transferred
After the dentist conducts an examination and the results of the tests appear, information is entered in the "diagnosis" column. The date is indicated.
Requirements for the diagnosis: a detailed and descriptive nature of the condition of the teeth and the oral cavity as a whole.
Describing the disease, the doctor specifies the time of appearance of the first signs, course, complaints of the patient, what treatment was carried out and with what result.
Diseases can be noted on a special insert, which is a. At repeated requests of the patient, entries should be made in the diary of the card.
Entries are made in legible handwriting, blots and corrections are excluded. Filling out can be done both by hand and typewritten - printed sheets are pasted into the medical card.
The attending physician records the dates of admission, the course of the disease and the effectiveness of the treatment, prescribed medications, procedures. Common names and abbreviations are used. All relevant information is entered after the patient's admission.
In addition to the required data, the following information can be entered:
- conclusions of dentists from other medical institutions;
- the results and data on the degree of exposure from such a survey;
- test results.
Now patients have the opportunity to maintain a personal medical record and communicate with their doctor using the Medcard24 platform. There is a similar platform for readers from Ukraine.
Where is stored, where can hide
This medical dental card of the patient contains personal data about health, their safety is guaranteed by law. When a client first contacts dentistry, he signs a consent to the storage, recording and processing of personal information, his personal data. Only with consent will the storage of such information by the clinic be considered lawful. Providing the patient's personal data to other persons is possible only if he has given permission for this, or if there is a court order.
The outpatient card of a dental patient is kept in the dental clinic for 5 years, which are calculated from the moment of the last visit of the client. Then it is handed over to the archive.
In the Letter of the Ministry of Health and Social Development of the Russian Federation dated 04.04.2005 N 734 / MZ-14, it is allowed to issue a card to the hands of the patient - but only with the permission of the head physician of the institution. The refusal may be motivated by the fact that this medical documentation is the property of dentistry, as well as a document of strict accountability.
At the same time, the client has the right to receive information about his health. He has the right to see his card. Upon request, he can be provided with extracts and copies containing information about the types of medical intervention, treatment and examination. In this way, the client will be able to receive complete information without taking the medical card outside the threshold of the medical institution.
Sample card statement:
If the patient makes a transfer from one clinic to another under the compulsory medical insurance policy, there is no need to require the issuance of a patient card in hand - the clinic receiving the patient will itself request documentation from the clinic serving the patient earlier. The transfer of the patient's hospital card is carried out by the management of the clinic within three days.
IV. SAMPLES OF COMPLETING THE MEDICAL CARD OF A DENTAL PATIENT IN THE TREATMENT OF MAIN DENTAL DISEASES
OPTIONS FOR RECORDING THE HISTORY OF DISEASE OF PATIENTS WHICH PPROVIDED TOOTH REMOVAL AND OTHER SURGICAL MANIPULATIONS
Exacerbation of chronic periodontitis
Complaints of pain in the region of the upper jaw on the left, it hurts at 27 when biting.
History of the disease. 27 previously treated, periodically disturbed. Two days ago, 27 fell ill again, there was pain in the region of the upper jaw on the left, pain when biting on 27 increases. History of influenza.
local changes. On external examination, there is no change. Submandibular lymph nodes are slightly enlarged on the left, painless on palpation. The mouth opens freely. In the oral cavity: under a filling, changed in color, its percussion is painful. In the region of the tops of the roots 27, a slight swelling of the mucous membrane of the gums is determined from the vestibular side, palpation of this area is slightly painful. On radiograph 27, the palatine root is sealed to the apex, the buccal roots are 1/2 of their length. At the apex of the anterior buccal root there is a rarefaction of bone tissue with fuzzy contours.
Diagnosis: "exacerbation of chronic periodontitis 27 tooth".
a) Under tuberal and palatine anesthesia with 2% novocaine solution - 5 mm or 1% trimecanne solution - 5 mm plus 0.1% adrenaline hydrochloride - 2 drops (or without it) extraction was performed (specify the tooth), curettage of the hole; hole filled with blood clot.
b) Under infiltration and palatine anesthesia (anesthetics, see entry above, indicate the presence of adrenaline), removal was performed (18, 17, 16, 26, 27, 28), curettage of the hole; hole filled with blood clot.
c) Under infiltration and palatine anesthesia (anesthetics, see entry above, indicate the presence of adrenaline), removal was performed (15, 14, 24, 25). Curettage of the hole (holes), the hole (s) filled (were) with a blood clot (s).
d) Under infraorbital and palatine anesthesia (anesthetics see above, indicate the presence of adrenaline) ( 15, 14, 24, 25).
e) Under infiltration and incisive anesthesia (anesthetics see above, indicate the presence of adrenaline) removal was performed (13, 12, 11, 21, 22, 23) . Curettage of the hole, it is compressed and filled with a blood clot.
f) Under infraorbital and incisive anesthesia (anesthetics see above, indicate the presence of adrenaline), the removal was performed (13, 12, 11, 21, 22, 23). Curettage of the hole, it is compressed and filled with a blood clot.
Acute purulent periodontitis
Complaints of pain in the area of 32, radiating to the ear, pain when biting on 32, a feeling of a "grown" tooth. The general condition is satisfactory; past illnesses: pneumonia, childhood infections.
History of the disease. About a year ago, for the first time, pain appeared at 32, it was especially disturbing at night. The patient did not go to the doctor; gradually the pain subsided. 32 days ago, pain reappeared; went to the doctor.
local changes. On external examination, there are no changes. The submental lymph nodes are slightly enlarged, painless on palpation. The mouth opens freely. In the oral cavity 32 - there is a deep carious cavity communicating with the tooth cavity, it is mobile, percussion is painful. The mucous membrane of the gums in area 32 is slightly hyperemic, edematous. There are no changes on the radiograph 32.
Diagnosis: "acute purulent periodontitis 32".
a) Under mandibular and infiltration anesthesia (anesthetics see above, indicate the presence of adrenaline), an extraction was performed (indicate a tooth) 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38; curettage of the holes, they are compressed and filled with blood clots.
b) Under torusal anesthesia (anesthetics see above, indicate the presence of adrenaline), 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38 were removed.
Curettage of the hole, it is compressed and filled with a blood clot.
c) Under bilateral mandibular anesthesia (anesthetics see above), removal of 42, 41, 31, 32 was performed. Curettage of the hole, it was compressed and filled with a blood clot.
d) Under infiltration anesthesia (anesthetics, see above, indicate the presence of adrenaline), 43, 42, 41, 31, 32, 33 were removed. Curettage of the hole, it was compressed and filled with a blood clot.
Acute purulent periostitis
Complaints of swelling of the cheek on the right, pain in this area, fever.
Past and concomitant diseases: duodenal ulcer, colitis.
History of the disease. Five days ago there was pain at 13; Two days later, a swelling appeared in the gum area, and then in the buccal area. The patient did not go to the doctor, applied a heating pad to his cheek, did warm intraoral soda baths, took analgesics, but the pain grew, the swelling increased, and the patient went to the doctor.
local changes. During external examination, a violation of the configuration of the face is determined due to swelling in the buccal and infraorbital regions on the right. The skin above it is not changed in color, painlessly gathers into a fold. The submandibular lymph nodes on the right are enlarged, compacted, slightly painful on palpation. The mouth opens freely. In the oral cavity: 13 - the crown is destroyed, its percussion is moderately painful, mobility II - III degree. Pus is released from under the gingival margin. The transitional fold in the area of 14, 13, 12 swells significantly, is painful on palpation, fluctuation is determined.
Diagnosis: "acute purulent periostitis of the upper jaw on the right in the area of 14, 13, 12 teeth"
Complaints of swelling of the lower lip and chin, extending to the upper part of the chin area; sharp pains in the anterior part of the lower jaw, general weakness, lack of appetite; body temperature 37.6 ºС.
History of the disease. After hypothermia a week ago, spontaneous pain appeared in the previously treated 41, pain when biting. On the third day from the onset of the disease, the pain in the tooth decreased significantly, but swelling of the soft tissues of the lower lip appeared, which gradually increased. The patient did not carry out treatment, he turned to the clinic on the 4th day of the disease.
Past and concomitant diseases: influenza, tonsillitis, intolerance to penicillin.
local changes. During external examination, swelling of the lower lip and chin is determined, its soft tissues are not changed in color, they fold freely. The submental lymph nodes are slightly enlarged, slightly painful on palpation. Opening the mouth is not difficult. In the oral cavity: the transitional fold in the region of 42, 41, 31, 32, 33 is smoothed, its mucous membrane is edematous and hyperemic. On palpation, a painful infiltrate in this area and a positive symptom of fluctuation are determined. Crown 41 is partially destroyed, its percussion is slightly painful, I degree mobility. Percussion 42, 41, 31, 32, 33 painless.
Diagnosis: "acute purulent periostitis of the lower jaw in the area of 42, 41, 31, 32".
Record of surgical intervention for acute purulent periostitis of the jaws
Under infiltration (or conduction - in this case, specify which one) anesthesia (anesthetic see above, indicate the presence of adrenaline), an incision was made along the transitional fold in the area
18 17 16 15 14 13 12 11 |21 22 23 24 25 26 27 28
(indicate within which teeth) 3 cm (2 cm) long to the bone. Got pus. The wound was drained with a rubber strip. Assigned (indicate the medications prescribed to the patient, their dosage).
The patient is disabled from _______ to _________, sick leave No. ______ issued. Appearance ______ for dressing.
Diary entry after opening a subperiosteal abscess in acute purulent periostitis of the jaw
The patient's condition is satisfactory. Improvement (or deterioration, or no change) is noted. Pain in the jaw area has decreased (or increased, remains the same). The swelling of the maxillary tissues has decreased, a small amount of pus is released from the wound in the oral cavity. The wound along the transitional fold of the jaw was washed with a 3% solution of hydrogen peroxide and a solution of furacilin at a dilution of 1:5000. A rubber strip has been inserted into the wound (or the wound has been drained with a rubber strip)
Complaints of pain in the hard palate on the left of a pulsating nature and the presence of swelling on the hard palate. The pain is aggravated by touching the swelling with the tongue.
History of the disease. Three days ago, there was pain in the previously treated 24, pain when biting, feeling of a “grown tooth”. Then the pain in the tooth decreased, but a painful swelling appeared on the hard palate, which gradually increased in size.
Past and concomitant diseases: hypertension II degree, cardiosclerosis.
local changes. During external examination, the configuration of the face was not changed. On palpation, an increase in the submandibular lymph nodes on the left is determined, which are painless. Mouth opening freely. In the oral cavity: on the hard palate on the left, respectively 23 24 there is a disgraced bulging with fairly clear boundaries, the mucous membrane over it is sharply hyperemic. Fluctuation is determined in the center of it. 24 - the crown is partially destroyed, a deep carious cavity. Percussion of the tooth is painful, tooth mobility I degree.
Diagnosis: "acute purulent periostitis of the upper jaw on the palatine side on the left (palatine abscess) from the 24th tooth."
Under palatine and incisive anesthesia (specify the anesthetic and the addition of adrenaline), an abscess of the hard palate was opened with excision of soft tissues down to the bone in the form of a triangular flap within the entire infiltrate, pus was obtained. The wound was drained with a rubber strip. Drug therapy was prescribed (specify which one).
The patient is disabled from _______ to _______., A sick leave sheet No. _______ was issued. Appearance _________ for dressing.
Acute purulent osteomyelitis
Complaints of shooting, boring pains in the region of the entire half of the lower jaw on the right, severe weakness, fever up to 39ºС, chills, sweating, bad breath.
The patient has no past or concomitant diseases.
History of the disease. Five days ago, pain appeared in the previously treated 46, pain when biting, swelling of the gums and cheeks on the right. There was chills at night. In the morning I went to the doctor. The tooth has been removed. Improvements have not come. Increased pain in the jaw, general weakness; there was numbness of the skin of the lower lip on the right, bad breath. Soft tissue swelling increased, body temperature increased.
local changes. An external examination reveals a significant swelling in the submandibular and buccal areas on the right, the skin above it is hyperemic, tense, and does not fold. Palpation of tissues is painful. Pain sensitivity of the skin of the lower lip and chin on the right is reduced. Palpation of the lower edge of the body of the lower jaw on the right is sharply painful. In the oral cavity: the mucous membrane of the alveolar part of the lower jaw in the area 48, 47, 46, 45 from the vestibular and lingual sides is edematous and hyperemic. Percussion 47, 45 is sharply painful, the teeth are mobile. Bulging is determined along the transitional fold in the area of 48, 47, 46, 45 from the vestibular side, infiltration of the soft tissues of the alveolar process in the area of these teeth from the lingual side. Hole 46 exudes pus.
Diagnosis: "odontogenic acute purulent osteomyelitis of the lower jaw on the right, inflammatory infiltrate of the submandibular and buccal regions on the right."
Under torusal anesthesia (specify the anesthetic), an incision was made along the transitional fold to the bone in the area of 47, 46, 45, 44, pus was obtained, and an incision was made in the area of the alveolar or germ from the lingual side (to the bone) within these teeth, no pus was obtained, stagnant blood was obtained. Wounds are drained with rubber strips. Drug therapy was prescribed (specify which one). The patient is disabled from _______ to, a sick leave sheet No. ______ was issued. Appearance _______ for dressing.
Odontogenic cystogranuloma
Complaints about recurring pain in 11. The tooth was previously treated with canal filling. He considers himself practically healthy.
local changes. During external examination, the configuration of the face was not disturbed. Submandibular and parotid lymph nodes are not palpable. The mouth opens freely. In the oral cavity: the mucous membrane is pale pink, well moistened. On palpation of the alveolar part of the upper jaw from the vestibular side, there is a slight swelling in the projection area of the apex 11. On the radiograph in the area of the apex 11, there is a rarefaction of the bone tissue of a rounded shape with clear contours with a diameter of 0.6 cm. Channel 11 is sealed with cement by 2/3.
Diagnosis: "cystogranuloma in area 11".
Recording of root apex resection operation
Under conduction (specify which) and infiltration anesthesia (specify the anesthetic and adrenaline solution, if any), a semi-oval (or trapezoid) incision was made in the soft tissues of the alveolar process to the bone. A flap has been formed with its base facing the transitional fold. The mucoperiosteal flap was detached in the area (indicate the formula of the teeth). An uzura was found in the compact plastic of the alveolar process (if any), which was expanded with a burr. The apex of the root was identified with a granuloma, the apex of the root was resected (indicate the formula of the tooth) with the help of a fissure bur, which was removed with a curettage spoon along with a cystogranuloma. The protruding part of the root is smoothed with a cutter to the bottom of the bone cavity. The wound was washed with a solution of furacilin 1:5000 and a solution of 0.05% chlorhexidine. The flap is placed in place and fixed with catgut sutures. Pressure bandages applied. Medical therapy was prescribed (specify which one).
The patient is disabled from _____ to __________, a sick leave sheet No. ______ is issued.
Appearance _______ for dressing.
Semi-retention and dystopia of teeth
Complaints of recurrent pain in the lower jaw on the left and difficulty opening the mouth. Past and concomitant diseases: influenza, intolerance to penicillin.
History of the disease. He considers himself sick for about 1 year. In January 2008 for the first time felt the appearance of painful swelling of the gums in area 37 and some difficulty in opening the mouth. He turned to the district clinic, where the treatment was carried out: 5 sessions of UHF therapy on the area of the angle of the lower jaw, took norsulfazol inside, and made baths with baking soda. The phenomena mentioned above subsided. He was referred for a consultation to the regional clinical dental clinic.
local changes. On external examination, the configuration of the face is not disturbed; on palpation, an enlarged (1 cm in diameter), painless, movable submandibular lymph node on the left is determined. Opening of the mouth is free, painless. In the oral cavity: the mucous membrane of the vestibule of the mouth is pale pink in color, sufficiently moistened. 38 was cut through by two distal tubercles, displaced towards 37.
On the radiograph, the crown 38 is displaced anteriorly, with medial tubercles adjacent to the root 37.
Diagnosis: "half-retention and dystopia 38".
Recording of tooth extraction with flap flap
Under infiltration or conduction (in this case, indicate which) anesthesia (anesthetic see above), an angular (or trapezoid, semi-oval) incision was made and the mucoperiosteal flap was detached in the area
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
(indicate within which teeth). A compact plate of alveolar bone tissue was trepanned with a burr in the area (indicate the formula of the tooth to be removed) from the vestibular side (when removing 48, 38 - additionally in the retromolar region). The bone tissue was removed with a burr.
The tooth was dislocated with an elevator and removed with forceps. The wound was washed with a 3% hydrogen peroxide solution, chonsuride (oxycelodex, hydroxyapatite, hemostatic sponge) was placed in it. The flap is put in place, the wound is sutured with catgut sutures. A pressure bandage was applied.
The patient is unable to work from ________ to ______, sick leave No. _________ issued. Drug therapy was prescribed (specify which one).
Retention cyst of the oral mucosa
Complaints about the formation of a spherical shape in the mucous membrane of the lower lip. Past and concomitant diseases: influenza, tonsillitis.
History of the disease. About 3 months ago, while eating, the patient bit his lower lip. A few days later, I noticed the appearance of a small formation in the thickness of the lip, which gradually increases, does not hurt, but interferes with eating. Has addressed to the doctor.
local changes. During external examination, the configuration of the face was not changed. Regional lymph nodes are not palpable. Opening of the mouth is free, painless. In the oral cavity: the mucous membrane is pale pink in color, sufficiently moistened. On the inner surface of the lower lip on the right, a rounded neoplasm with a diameter of 0.7 cm is determined, which differs in color from the surrounding mucous membrane. On bimanual palpation in the thickness of the lower lip, a rounded shape, formation, soft-elastic consistency, painless, movable, is determined.
Diagnosis: "retention cyst of the lower lip."
Recording of the operation of removal of the retention cyst of the lower lip
Under infiltration anesthesia (specify anesthetic), two semi-oval converging incisions were made to cut the mucous membrane of the lip. Bluntly and sharply, the retention cyst was isolated from the surrounding tissues, hemostasis. The wound was sutured with catgut sutures. A pressure bandage was applied. The removed preparation was sent for histological examination.
The patient is disabled from _______ to ___________, sick leave No. ______ issued. Appearance _____________ for dressing.
Papilloma of the tongue
Complaints about a neoplasm on the tip of the tongue. Past and concomitant diseases: hypertension stage II.
History of the disease. The patient noticed the appearance of a neoplasm on the coccyx of the tongue about 3 months ago, when a bridge was made at 43, 33. He notes the gradual growth of the neoplasm.
local changes. During external examination, no violation of the configuration of the face was noted. Regional lymph nodes are not palpable. Opening of the mouth is free, painless. In the oral cavity: the mucous membrane is pale pink, well moistened. At the tip of the tongue there is a neoplasm 0.5 cm in size, on a narrow stalk. On palpation - soft, painless, mobile. On the mucous membrane of the neoplasm there are fringed outgrowths, barely noticeable upon examination.
Diagnosis: papilloma of the tongue.
Recording the operation of excision of a benign neoplasm (papilloma, fibroma, etc.)
Under infiltration anesthesia (specify the anesthetic) two semi-oval converging incisions were used to excise the neoplasm of the mucous membrane (specify the organ) within healthy tissues up to the muscle layer. The wound was sutured with catgut sutures. The removed neoplasm was sent for histological examination.
The patient is unable to work from ________ to _______, sick leave No. ______ issued. Appearance ________ for dressing.
Radicular cyst of the jaw
Example 11.
Complaints of painless swelling in the region of the upper jaw on the left, raising the upper lip.
Past and concomitant diseases: the patient is practically healthy.
History of the disease. Previously, periodically ill 22, but the patient did not go to the doctor. I noticed swelling about 2 years ago. He noted a gradual increase. Currently, due to a cosmetic defect, he is sent for a consultation to the regional clinical dental clinic.
local changes. On external examination, there is a slight swelling of the upper lip on the left. The skin is under swelling of the usual color, it gathers well in a fold, on palpation the tissues are soft, painless. Regional lymph nodes are not palpable. Opening of the mouth is free, painless. The base of the lower nasal passage is raised on the left (Gerberian ridge). In the oral cavity: the mucous membrane is pale pink in color, sufficiently moistened. A limited swelling of a semi-oval shape is determined from the vestibular side of the alveolar part of the upper jaw in the region of 11, 21, 22, 23 teeth. The mucous membrane over the swelling is pale with a pronounced vascular pattern. On palpation, the swelling is supple, moderately dense, painless. In the center of it, a mild symptom of a parchment crunch is determined. Crowns of 21, 22 teeth converge, 21 is discolored, its percussion is painless.
Dental formula:
On the radiograph of the alveolar process of the upper jaw, bone tissue rarefaction is determined in the area 11,21,2 2,23 teeth with even and clear rounded contours. The site of rarefaction of bone tissue extends to the bottom of the nose. Conducted EOD: 21, 22 teeth do not respond to currents above 200 mA.
Diagnosis: "radicular cyst of the upper jaw in the area of 11,21,22,23 teeth, pushing the bottom of the nose."
Recording a cystectomy operation
The roots of the teeth, in which the apex is resected, are sealed with phosphate-cement in advance during the operation. Under conduction (specify which) and infiltration anesthesia (specify anesthetic), a semi-oval (or trapezoid) incision of the mucous membrane and periosteum to the bone was made. A flap was formed with its base facing the transitional fold in such a way that the future bone wound was somewhat smaller than the soft tissue flap. Peel off the mucoperiosteal flap in the area (indicate which teeth).
A pattern was found in a thinned and swollen compact plate of the bone of the alveolar process, which was expanded in pieces until the anterior wall of the cyst membrane was completely exposed. The shell of the radicular cyst was found and completely isolated, the tops of the roots were resected (indicate the dental formula), which were removed along with the shell of the radicular cyst. The sharp edges of the resulting cavity are smoothed with a milling cutter, they carry out hemostasis and the toilet of the surgical wound and the mucoperiosteal flap. If necessary, the postoperative bone cavity is filled with hemostatic, replacing or optimizing reparative osteogenesis preparations. The flap is put in place, the wound is sutured with catgut sutures. A pressure bandage was applied. The material was sent for histological examination.
The patient is disabled from _______ to __________, sick leave No. __________ issued. Medical therapy prescribed (specify).
Recording of the cystotomy operation
Under conduction (specify which) and infiltration anesthesia (specify anesthetic), a semi-oval incision was made so that it coincided with the boundaries of the bone wound. The mucoperiosteal flap was detached in the area (indicate the formula of the teeth). A bone pattern was found, which was expanded with a bur and wire cutters within the full diameter of the cyst. The cyst shell was exposed and its anterior wall was excised along the border of the bone wound. The causative tooth has been removed. The cyst cavity was washed with 3% hydrogen peroxide solution. Mucosal
the periosteal flap is placed in the cyst cavity, into which an iodoform tampon is tightly inserted in layers, fixing the flap (or the edge of the mucoperiosteal flap is sutured to the cyst membrane). A pressure bandage was applied. The material was sent for histological examination.
The patient is unable to work from _______ to ______, sick leave No. ______ issued. Medical therapy was prescribed (specify which one). Appearance _________ for dressing.
