Download - Fisa de Observatie Endodontie - Model
UNIVERSITATEA DE MEDICIN I FARMACIE "GR
UNIVERSITATEA DE MEDICIN I FARMACIE "GR. T. POPA IAIFACULTATEA DE MEDICIN DENTARNr. fi: _________________
Medic: __________________
Student: ________________
FOAIE DE OBSERVAIE- ENDODONIE -date generale
Nume:
______________________Prenume:______________________
Vrsta:
______________________Adresa:
______________________
Tel. fix:
______________________Tel. mobil:______________________
Loc munc:______________________Ocupaie:______________________MOTIVELE PREZENTRII
( durere
( tulburri masticatorii
( tulburri fizionomice
( sngerare gingival( continuare tratament (control)
( consult interdisciplinar
ANTECEDENTE PERSONALE
Antecedente personale generale
( nesemnificative
(semnificative
Meniuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________Starea general actual
( permite tratamentul
( temporizeaz tratamentul
( necesit precauii
( necesit spitalizare
Meniuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________
Antecedente personale stomatologice
Extracii:Anul ______ Cauza ______Dinte ______Tratamente odontale:
( rare
( multiple ( finalizate
( nefinalizateTratamente parodontale: ( rare
( multiple( de ntreinere
( chirurgicaleTratamente protetice
( conjunct( adjunct( satisfctoare( nesatisfctoareTratamente ortodontice:
( aparate fixe
( aparate mobile
( satisfctoare
( nesatisfctoare
Tratamente chirurgicale OMF:Anul ______Tipul: _________________________________________
Meniuni: _____________________________________________________________________________________________________________
ISTORICUL afeciunii actuale pe dinteCadranul ICadranul IICadranul IIICadranul IV
12345678123456781234567812345678
1Debut
acut
insiduos
2Evoluie
lent
rapid
3Tratamente efectuate
eficiente
ineficiente
Examen clinic extraoral
Pri moi:
( inspecie
( palpareStructuri osoase:
( inspecie
( palpare
Puncte trigeminale:
( inspecie
( palpareGanglioni:
( inspecie
( palpareATM:
( inspecie
( palpareMeniuni: ___________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________
EXAMEN CLINIC INTRAORAL
Orificiu bucal
( inspecie
( palpareVestibul maxilar
( inspecie
( palpare Vestibul mandibular
( inspecie
( palpare
Mucoas palatin
( inspecie
( palpareLimb
( inspecie
( palpare
Planeu
( inspecie
( palpareMucoas alveolar maxilar
( inspecie
( palpareMucoas alveolar mandibul
( inspecie
( palpareParodontiu
( inspecie
( palpareMeniuni: _____________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
EXAMENUL OCLUZIEI
Modificri ale ocluziei _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Meniuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________
Oglinda dentar
Meniuni: _____________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Pacient _____________________
Nr. fi _____________________Medic _____________________
Student _____________________
Dinte ______Semne subiectiveDurereaTip i intensitate:
( jen
( medie
( vie
( violent
( pulsatil
( lancinantDurata:
( pe durata excitantului ( minute 1 10p
( zeci de minute / ore
( episoade / crize( permanentApariie:
provocat
( cald
( rece
( dulce
( acru
( mecanic
spontan
( diurn
( frecvent nocturn
( n episoade (crize)
( spontan Amendare:
( spontan
( rece
( cald
( ocluzie
( antialgice uzualeLocalizare:
( localizat
( iradiat dini vecini,
hemiarcad,
hemifacies,
zone de vecintateSenzaia de egresiune
( absent
( prezentHalena fetid
( absent
( prezent
Semne obiectiveInspecieCoroanaCoroana:
( integr
( proces carios
( fractura
cu deschiderea camerei pulpare fr deschiderea camerei pulpare
-( obturatie provizorie( obturaie definitiv
( coroan de nveli
( abraziune
( atriie
( polip pulpar roz pal rou intens
( esut pulpar ulceratRdcina:
( expus
( neexpusa
( pung parodontal prezent( pung parodontal absentMucoasa alveolar:
( aspect normal
( congestie
( edem
( tumefacie
( fistul
( nodul
oral
vestibular activ
cicatrizat
PalpareDinte
Dentin
( dur
( ramolitSpaiu de percolare
( prezent
( absentMobilitate obturaie
( prezent
( absentSensibilitate dureroas
( marginile cavitii
( fundul cavitii
( camera pulpar
( canal radicular
Sngerare
( papila interdentar
( camera pulpar( canal radicular Secreii intracanalare
( exsudat purulent
( sanguino-purulent( exsudat clarMobilitate
( coronar
( corono-radicularMucoasa alveolarSensibilitate dureroas
( moderat
( accentuatZona
( indurat( fluctuent( renitent
( crepitaiiExprimare de secreie prin fistula
( prezent ( absentPercuia
Percuia n ax
( negativ
( uor pozitiv
( intens pozitiv
Percutia transversala
( negativ
( uor pozitiv
( intens pozitivAuscultaie
Sunet
( normal
( matTeste de vitalitateTipul testului de vitalitate
( electric
( termic la cald
( termic la rece ( foraj exploratorRezultate test de vitalitate
( normale
( hiperexcitabilitate
( hipoexcitabilitate ( negative EXAMENE RADIOGRAFICE
Tratament endodontic
Corect
( da
( nu
Incorect
( subdimensionat
( supradimensionat
( neetan
( neobturat
Pivot radicular
( prefabricat
( turnatCai false
( prezente
( absenteCorpi strini
( prezeni
( abseni Pulpolii
( prezeni
( abseni
Morfologie canalar
( favorabil tratamentului( nefavorabil tratamentuluiPeriapicalNormalRadiotransparen
1 5 mm5 10 mm> 10mm
preoperator
postoperator
la 6 luni
la 1 an
la 2 ani
Odontometrie: reper........................Canal\mm
1516171819202122232425262728
Unic
V.
P.
M.V.
D.V.
M.L.
D.
DIAGNOSTIC
Hiperemie preinflamatorie
Pulpita acuta seroasa partiala
Pulpita acuta seroasa totala
Pulpita acuta purulenta partiala
Pulpita acuta purulenta totala
Pulpita cronica deschisa ulcerosa
Pulpita cronica deschisa polipoasa
Pulpita cronica inchisa propriu-zisa
Granulom intern Palazzi
Necroza pulpara Gangrena pulpara simpla
Parodontita apicala acuta hiperemica
Parodontita apicala acuta seroasa
Parodontita apicala acuta purulenta
Parodontita apicala cronica fibroasa
Granulom simplu conjunctiv
Granulom epitelial
Granulom chistic
Parodontita apicala cronica difuza
Parodontita apicala cronica condensanta
Mentiuni:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
.............................................................................................................................................................................PLAN GENERAL DE TRATAMENT Biopulpectomie
Debridare mecano-chimica
Tratament medicamentos Obturare radiculara definitiva Interventie chirurgicala
Reconstituire coronara
Reconstituire corono-radiculara
Monitorizarea pacientului
MANOPERE EFECTUATENr. crt.ManopereData
S1S2S3
1. Consultaie
2. Stabilire diagnostic
3. Stabilire plan de tratament
4. Educaie sanitar
5. Detartraj / Periaj profesional
6. Anestezie loco-regional / plexal
7. Anestezie intrapulpar
8. Ablaie obturaie coronar / coroan nveli
9. Exereza dentinei alterate
10. Coafaj indirect / direct
11. Aplicare pansament calmant
12. Realizarea cavitii de acces
13. ndepartarea pulpei coronare
14. Hemostaza
15. ndepartarea pulpei radiculare
16. Evidarea coninutului camerei pulpare
17. Evidarea coninutului canalar
18. Debridare mecano-chimic (EDTA)
19. ndeprtare obturaie canal / corpi strini
20. Drenaj endodontic
21. Incizie mucoperiostal
22. Irigaii H2O2
23. Irigaii hipoclorit de Na
24. Irigaii digluconat de clorhexidin
25. Stabilirea lungimii de lucru
26. Modelare canalar
27. Aplicare past medicamentoas
28. Aplicare past Ca (OH)2
29. Alegerea conului principal
30. Uscare canale cu conuri de hrtie
31. Aplicarea sigilantului
32. Introducere gutaperc
33. Obturaie provizorie coronar
34. Examen radiologic
35. Aplicare pivoturi intracanalare
36. Refacere definitiv coronar
Am luat cunotin i sunt de acord cu tratamentul prescris.
Pacient,
____________________
tratamente efectuate + deviz
Nr. crt.DataManoper (Cod)TarifSubtotal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Diagnostic final________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Caz terminat
Medic,
Pacient,
____________________
____________________
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