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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