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-I rauUNIVERSITATEA DE MEDICIN I FARMACIE "GR. T. POPA IAI FACULTATEA DE MEDICIN DENTAR
Nr. fi: ________________ Medic: _________________ Sudent: ________________Specialist Primar
Student
Nespecialist
FOAIE DE OBSERVA IE - PARODONTOLOGIE DATE GENERALENume: Vrsta : Adresa: Tel. fix: Loc munc: ______________________ Prenume: ______________________ Sex ______________________________________ ______________________ Tel. mobil: ______________________ Ocupa ie: ______________________ ______________________ ______________________ ______________________ ______________________
Men iuni: _____________________________________________________________________________________________________________
MOTIVELE PREZENTRIIsngerare gingival probleme estetice legate de recesiuni sau migrri dentar tulburri masticatorii legate de mobilitate dentar halitoz, gust neplcut n cavitatea oral senza ie tensiune sau prurit la nivelul gingiei simptomatologie legat de complica iile bolii parodontale (abcese parodontale, parestezii, sindrom endo-parodontal) probleme odontale (carii simple i complicate) probleme endodontice (durere cu caracterele specifice)
ISTORICUL AFEC IUNII PARODONTALEDurat Debut Semne de debut Evolu ie A mai fost tratat? zile _______ luni _______ lent provocat sngerare durere stagnant lent periodicitate da ani _______ brusc neprovocat tumefac ie mobilitate rapid n pusee (stare de activitate / inactivitate) nu
ANTECEDENTE ANTECEDENTE HEREDO-COLATERALEAntecedente heredo-colaterale generale:Men iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________ ______________________________________________________________________________________
Antecedente heredo-colaterale stomatologice:Men iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________ ______________________________________________________________________________________
ANTECEDENTE PERSONALEAntecedente personale generale:Men iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________ ______________________________________________________________________________________
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Antecedente personale stomatologice:Men iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________ ______________________________________________________________________________________
CONDI II DE VIA I MUNCMen iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________ ______________________________________________________________________________________
FACTORII DE RISC PARODONTALVrsta: _______ Obiceiuri vicioase: fumat alcool frecven tip Tipul de alimenta ie (carbohidra i, etc.): da da nr. igri / zi ______ cosumator ocazional bere vin nu nu de cnd ______ luni / ______ ani frecvent trii cronic
Men iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________ Igiena oral deficitar: periaj dentar nr. periaje / zi ______ tip periaj __________________ substan e antiplac folosire zilnic rar Tratamente dentare defectuoase: lucrari protetice obtura ii Malocluzii: da nuMen iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________ Respira ia oral: da nuMen iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________ Istoric de boala parodontal: da nu da nu Stresul: Afec iuni sistemice (teren imunocompromis): diabet afec iuni cardiovasculare afec iuni hematologice afec iuni virale infec ia HIV Stri fiziologice: pubertatea sarcina menopauza Factori ereditari:Men iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________ Etnia: _________________________________________________________________________________
IGIENAbun medie necorespunztoare
PERIAJUL DENTARRitmicitate: Tehnica periaj: dup fiecare mas incorect diminea a i seara corect bass charters bass modificat rotativ neregulat
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PERIU
A DENTARmanual moale 3 luni electric medie deteriorare dur
Tipul periutei: Duritate: Schimbat la:
PASTA DE DIN
Icosmetic medical
MIJLOACE SUPLIMENTARE DE IGIENA ORALApe de gur Fir interdentar Periu e interdentare Scobitori interdentare Duuri bucale cronologia cltirilor ______________________________________ durata cltirii ________________________________________ da nu da nu da nu da nu
INDICI DE IGIENIndice de plac: ___________________________________________________________________ Indice de plac PLI (Silness & Loe) ______________________________________________________ Indice de tartru ___________________________________________________________________Men iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________
EXAMEN EXOBUCAL TEGUMENTE / MUCOASEAspect Culoare Integritate Sensibilitate Tumefac ii Adenopatii _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
Men iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________
EXAMEN CLINIC PARODONTALParodon iu de nveliGingia marginalCuloarea: roz-coral rou intens rou-violaceu Consisten a: ferm moale Forma: _________________________________________________________________________ Textura: granitat neted Volum: _________________________________________________________________________ Pozi ia: zona de pe arcad unde apar modificri. Inflama ie: localizare localizat generalizat zona _________________________________________________ form: acut periodic cronic
Gingia ataatabsent zona _________________________________________________
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ngust lat
zona _________________________________________________ zona _________________________________________________
Frenuri brideInserare: aproape mediu la distan zona _________________________________________________ zona _________________________________________________ zona _________________________________________________
Indicele PSR / sextan i (cod 0, 1, 2.4)Sextant 1 __________________ Sextant 6 __________________ Sextant 2 __________________ Sextant 5 __________________ Sextant 3 __________________ Sextant 4 __________________
Parodon iul de sus inerePungi parodontale: supraosoase infraosoase mixte
Sngerareaabsent la periaj malpozi ii la sondaj mobilitate spontan
Din iimigrri
PARODONTOGRAMA INI IALIndice de sntate a papilei inter-dentare:
Men iuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________ ______________________________________________________________________________________
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MAXILAR
Indicele gingival sau GI: indicele lui Le i Silness (0, 1, 1,5) ______________________________________________________________________ Indice de sngerare papilar PBI ______________________________________________________________________ Indice de sngerare gingival ______________________________________________________________________
Indice de hipercretere ______________________________________________________________________ Indicele CPITN - Community Periodontal Index (0, 1, 2, 3, 4, 5, 6) ______________________________________________________________________ Indice de mobilitate(0, 1, 2, 3) ______________________________________________________________________
Men iuni: _______________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________ 5
MANDIBULAR
Indicele gingival sau GI: indicele lui Le i Silness (0, 1, 1,5) ______________________________________________________________________ Indice de sngerare papilar PBI ______________________________________________________________________ Indice de sngerare gingival ______________________________________________________________________
Indice de hipercretere ______________________________________________________________________ Indicele CPITN - Community Periodontal Index (0, 1, 2, 3, 4, 5, 6) ______________________________________________________________________ Indice de mobilitate(0, 1, 2, 3) ______________________________________________________________________
Men iuni: _______________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________ 6
DIAGNOSTIC PARODONTALCod 1Cadranul I Cadranul II Cadranul III Cadranul IV 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Integritatea parodontal Anatomo-clinic + forma clinic Abces parodontal 1.1 Gingivita necomplicata 1.1.1 modulata 1.1.2endocrin medicamentos
1.2 1.3 1.3.1 1.3.2 1.3.3 1.3.3.1 1.3.3.2 1.3.3.3 1.3.4 1.3.5 1.3.6 2 2.1 2.2 3 3.1 3.2 3.3 3.4 3.5 3.6 3.8 3.9 4 4.1 4.2 4.3 4.4 5 5.1 5.2 5.3 6 6.1 6.2 6.3 6.4 7 7.1 7.2 7.3 8 8.1 8.2 8.2.1 8.2.2 8.2.3 8.2.4
Gingivita ulcero-necrotic Parodontita juvenila rapid progresiva a adultuluisuperficiala medie profunda
refractara din SIDA ulcero-necrotica Topografie Localizat Generalizat Etiologie Microbian Teren Stri fiziologice Patologii sistemice Medica ie Traumatic Iatrogenic Plurifactorial Tulburri func ionale Masticatorio Fizionomice Fonetice Degluti ie Evolu ie Stabilizat Lent Rapid Complica ii Locale La distan Imediate Tardive Prognostic Favorabil Rezervat Nefavorabil Tratament Netratat Tratatcorect incorect complet incomplet
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PLAN DE TRATAMENT TRATAMENTUL ETIOLOGICCod (A) 1 2 3 Manopere Consultatia in cadrul dispensarizarii (include si educatia pentru sanatatea bucodentara, determinarea indicelui de placa bacteriana si a indicilor de inflamatie parodontali) Educatia pentru individualizarea tehnicilor de indepartare a placii bacteriene / sedinta Periaj dentar profesional / sedintaNr. edin e 1 2 3 4 5 6 7 8
Igiena oral:Periu a de din i: Metoda de periaj: Periu a interdentar: Firul interdentar: Cltiri antiseptice:Cod (E) 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Manopere
soft circular da da daCadranul I
medium Charters nu nu nuCadranul II
hard Bass
Cadranul III
Cadranul IV
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
Profilaxia i tratamentul antimicrobian Detartraj manual supra si subgingival per dinte Detartraj mecanic supra si subgingival per dinte Detartraj ultrasunete Surfasaj radicular / dinte
Periaj profesional / dinteTratament medicamentos local Tratamentul abcesului parodontal
TRATAMENTUL CORECTIV2 2.1 2.2 2.3 2.4 2.5 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Tratamentul chirurgical Chiuretaj in camp inchis Chiuretaj parodontal in camp deschis / sextant Echilibrare ocluzala prin slefuire selectiva per sedinta Tratamentul aftei bucale per sedinta Tratamentul gingivo stomatitelor per sedinta Conten ie / imobilizare Contentie provizorie prin ligaturi de sarma Imobilizare cu compozite Imobilizare cu amalgam Imobilizare cu compozit i srm Imobilizare cu compozit i plas de srm Imobilizare cu compozit i band de polifibr Pun i stabilizatoare
ETAPA DE MENCod (A) 1
INERE / CONTROL (la 3 luni, 6 luni, 1 an)Nr. edin e 1 2 3 4 5 6 7 8
Manopere Consultatia in cadrul dispensarizarii (include si educatia pentru sanatatea bucodentara, determinarea indicelui de placa bacteriana si a indicilor de inflamatie parodontali)
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MAXILAR
Indicele gingival sau GI: indicele lui Le i Silness (0, 1, 1,5) ______________________________________________________________________ Indice de sngerare papilar PBI ______________________________________________________________________ Indice de sngerare gingival ______________________________________________________________________
Indice de hipercretere ______________________________________________________________________ Indicele CPITN - Community Periodontal Index (0, 1, 2, 3, 4, 5, 6) ______________________________________________________________________ Indice de mobilitate(0, 1, 2, 3) ______________________________________________________________________
Men iuni: _______________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________ 9
MANDIBULAR
Indicele gingival sau GI: indicele lui Le i Silness (0, 1, 1,5) ______________________________________________________________________ Indice de sngerare papilar PBI ______________________________________________________________________ Indice de sngerare gingival ______________________________________________________________________
Indice de hipercretere ______________________________________________________________________ Indicele CPITN - Community Periodontal Index (0, 1, 2, 3, 4, 5, 6) ______________________________________________________________________ Indice de mobilitate(0, 1, 2, 3) ______________________________________________________________________
Men iuni: _______________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________ 10
EVOLU IA PACIENTULUI + DEVIZNR. CRT. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 DATA MANOPER (COD) TARIF MATERIAL
DIAGNOSTIC FINAL______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
Caz terminat
Medic,
Pacient,
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