Medical card. Recommendations for students on filling out a medical record of a dental patient with defects of hard dental tissues Filling out a dental examination record

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 data about patients and the progress of treatment.

A dental patient card form 043 is issued for all citizens who seek help. The document exists in one copy for each patient. The number of specialists who took part in the treatment of the patient does not matter. All data is compiled into 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. 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 must contain the patient’s passport data. This sheet is filled out at the registration desk. The basis is documents proving the identity of the applicant. The patient enters information about his health into the card.

Health information should include: important parameters, such as allergies, blood type and Rh factor, chronic diseases internal organs, existing head injuries, medications currently taken, etc. It is extremely important to provide 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 visual examination and x-ray examinations. The use of an X-ray machine involves exposing the patient to radiation. The received radiation dose must also be recorded in the card.

Pages with examination results, data on diagnosis and treatment progress are filled out by specialists performing the relevant procedures. The patient must document his or her agreement to the examination and treatment plan.

An important feature of filling out the form is the ability to write down the names of drugs in Latin. The rest of the information is entered only in Russian. Text entered by hand must be legible. Corrections are confirmed by signature.

Medical card 043 y is the property of the clinic.

According to the instructions, dental card form 043 is not issued in person. This legal document can be used in the event of litigation and claims from the patient. In an outpatient dental facility, the card is stored for 5 years. After the lapse of given period The form is transferred to the organization’s archives. The archival storage period is 75 years.

Unlike most established forms of medical forms, Form 043 is advisory. The form can be supplemented and adjusted to suit the needs of a specific medical institution. In the City Blank printing house it is possible to order such an adjustment of the form, taking into account all the customer’s requirements.

The document can be shortened, supplemented, and columns adjusted. To save protective functions document, it is recommended not to exclude important points 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 dental patient’s medical record either in a single copy or 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.

OPTIONS FOR RECORDING THE ILLNESS HISTORY OF PATIENTS WHO ARE SUGGESTED TOOTH EXTRACTION AND OTHER SURGICAL MANIPULATIONS

^

Exacerbation of chronic periodontitis

Complaints of pain in the area upper jaw on the left, it hurts at 27 when biting.

History of the disease. 27 was previously treated, periodically bothered. Two days ago, 27 fell ill again, pain appeared in the area of ​​the upper jaw on the left, the pain when biting on 27 increases. History of influenza.

Local changes. There is no change during external examination. Submandibular The lymph nodes slightly enlarged on the left, painless on palpation. The mouth opens freely. In the oral cavity: 27 under a filling, the color is changed, its percussion is painful. In the area of ​​the apex of roots 27, a slight swelling of the mucous membrane of the gums on the vestibular side is detected; palpation of this area is slightly painful. On X-ray 27, the palatal root is sealed to the apex, the buccal roots are sealed to 1/2 of their length. There is a vacuum at the apex of the anterior buccal root bone tissue with fuzzy contours.

Diagnosis: "exacerbation chronic periodontitis 27 teeth."

A) Under tuberal and palatal 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 tooth), socket curettage ; the hole filled with a blood clot.

B) Under infiltration and palatal anesthesia (anaesthetics, see the entry above, indicate the presence of adrenaline), removal (18, 17, 16, 26, 27, 28) was performed, curettage of the hole; the hole filled with a blood clot.

B) Under infiltration and palatal anesthesia (anaesthetics, see the entry above, indicate the presence of adrenaline), removal was performed (15, 14, 24, 25). Curettage of the socket(s), the socket(s) became filled with blood clot(s).

D) Under infraorbital and palatal anesthesia (see anesthetics above, indicate the presence of adrenaline), removal was performed ( 15, 14, 24, 25).

E) Under infiltration and incisive anesthesia (see anesthetics 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.

E) Under infraorbital and incisal anesthesia (see anesthetics 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.
^

Acute purulent periodontitis

Complaints of pain in the area of ​​32, radiating to the ear, pain when biting on 32, a feeling of an “overgrown” tooth. General state satisfactory; past diseases: pneumonia, childhood infections.

History of the disease. About a year ago, pain first appeared at 32, and was especially bothersome at night. The patient did not see a doctor; gradually the pain subsided. About 32 days ago the pain reappeared; consulted a doctor.

Local changes. There are no changes upon external examination. The submental lymph nodes are slightly enlarged and 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 and swollen. There are no changes on X-ray 32.

Diagnosis: “acute purulent periodontitis 32".

A) Under mandibular and infiltration anesthesia (see anesthetics above, indicate the presence of adrenaline), removal of (specify tooth) 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38 was performed; curettage of the holes, they are compressed and filled with blood clots.

B) Under torusal anesthesia (see anesthetics 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 (see anesthetics above), 42, 41, 31, 32 were removed. Curettage of the hole, it was compressed and filled with a blood clot.

D) Under infiltration anesthesia (see anesthetics 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 right cheek, pain in this area, increased body temperature.

Previous and concomitant diseases: duodenal ulcer, colitis.

History of the disease. Five days ago pain appeared at 13; two days later swelling appeared in the gum area, and then in buccal area. The patient did not go to the doctor; he applied a heating pad to his cheek and performed warm intraoral soda baths, took analgia, but the pain grew, the swelling increased, and the patient consulted a doctor.

Local changes. An external examination reveals a violation of the facial configuration due to swelling in the buccal and infraorbital areas on the right. The skin over it is not changed in color, it folds painlessly. The submandibular lymph nodes on the right are enlarged, compacted, and slightly painful on palpation. The mouth opens freely. In the oral cavity: 13 - the crown is destroyed, its percussion is moderately painful, mobility is II – III degree. Pus is released from under the gingival margin. The transitional fold in the area 14, 13, 12 bulges significantly, is painful on palpation, and fluctuation is detected.

Diagnosis: “acute purulent periostitis of the upper jaw on the right in the area of ​​14, 13, 12 teeth”

Example 4.

Complaints of swelling lower lip and chin, extending to upper section submental area; sharp pains V anterior section 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 undergo treatment; he went to the clinic on the 4th day of the disease.

Previous and concomitant diseases: influenza, sore throat, penicillin intolerance.

Local changes. An external examination reveals swelling of the lower lip and chin, soft fabrics its color is not changed, it is folded freely. The submental lymph nodes are slightly enlarged and slightly painful on palpation. Opening the mouth is not difficult. In the oral cavity: the transitional fold in the area of ​​42, 41, 31, 32, 33 is smoothed, its mucous membrane is swollen and hyperemic. On palpation, a painful infiltrate in this area is determined and positive symptom fluctuations. Crown 41 is partially destroyed, percussion is slightly painful, mobility is grade I. Percussion of 42, 41, 31, 32, 33 is painless.

Diagnosis: “acute purulent periostitis of the lower jaw in the area of ​​42, 41, 31, 32.”

^ Record surgical intervention for acute purulent periostitis of the jaws

Under infiltration (or conduction - in this case, specify which one) anesthesia (see the anesthetic 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

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

(specify within which teeth) 3 cm (2 cm) long to the bone. Pus was obtained. The wound was drained with a rubber strip. Assigned (specify medications prescribed to the patient, their dosage).

The patient is incapacitated from _______ to _________, issued sick leave No. ______. Appearance ______for dressing.

^

Diary entry after opening a subperiosteal abscess in acute purulent periostitis of the jaw

The patient's condition is satisfactory. There is an improvement (or worsening, or no change). The pain in the jaw area has decreased (or increased, remains the same). The swelling of the perimaxillary tissues has decreased, and 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 furatsilin at a dilution of 1:5000. A rubber strip is inserted into the wound (or the wound is drained with a rubber strip)

Example 5.

Complaints of pain in the area hard palate on the left, pulsating in nature and the presence of swelling on the hard palate. The pain intensifies when touching the swelling with the tongue.

History of the disease. Three days ago, pain appeared in the previously treated 24, pain when biting, and a feeling of an “overgrown 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: stage II hypertension, cardiosclerosis.

Local changes. Upon external examination, the configuration of the face was not changed. Palpation reveals an increase in the submandibular lymph nodes on the left, which are painless. Mouth opening freely. In the oral cavity: on the hard palate on the left, respectively 23 24 there is an opal-shaped bulge with fairly clear boundaries, the mucous membrane above it is sharply hyperemic. At its center there is a fluctuation. 24 - the crown is partially destroyed, there is a deep carious cavity. Percussion of the tooth is painful, tooth mobility is grade I.

Diagnosis: “acute purulent periostitis of the upper jaw on the palatal side to the left (palatal abscess) from the 24th tooth.”

Under palatal and incisal anesthesia (specify the anesthetic and the addition of adrenaline), an abscess of the hard palate was opened with excision of soft tissue to the bone in the form of a flap triangular shape within the entire infiltrate, pus is obtained. The wound was drained with a rubber strip. Appointed drug therapy(specify which one).

The patient is incapacitated from _______ to _______., sick leave No. _______ was issued. Show up _________for dressing.

AT THE DEPARTMENT OF ORTHOPEDIC DENTISTRY

Medical record of a dental patient

The main document for recording the work of a dentist of any specialty is the medical record of a dental patient, form 043-u, approved by order of the USSR Ministry of Health No. 000 dated 01/01/2001.

Medical card (outpatient card or medical history) – mandatory document medical outpatient appointment, performing following functions:

· is a plan for a thorough examination of the patient;

Count « Allergy history» the patient is asked whether there have been any allergic reactions to medical supplies, facilities household chemicals, food products etc., whether anesthesia was previously used, and whether any complications were noted after it.

For diagnostics pathological condition The dental system must be thoroughly studied patient's dental status followed by detailed description it in the medical record.

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

When describing the results of an external examination Special attention should be given:

signs of a change in proportions - a decrease in height lower section face, which may be due to significant destruction large quantity chewing teeth, increased abrasion of hard dental tissues;

· nature of movements of the lower jaw;

· the nature of the movements of the heads of the temporomandibular joints (which is determined by palpation).

Example: The face is symmetrical and proportional. Opening the mouth in in full. Movements of the lower jaw are free and uniform.

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

Example:

PWithRShtZ P K K

1812 11 !26 27 28

4842 41 !36 37 38

S PP K K

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

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

Example:

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

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

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

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

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

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

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

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

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

In the column "Bite" record data on the nature of the relationships of the dentition in position 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 lower teeth more than 1/3. Violation of the surface of the closure of the dentition due to the advancement of the 46th tooth relative to the occlusal surface by 1.5 mm (or by ¼ of the height of the crown). There is hypertrophy of the alveolar process in the area of ​​46, exposure of the neck of the tooth.

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

· condition of the crown – presence of a carious cavity, filling, relationship between the bottom of the carious cavity and the tooth cavity;

· characteristics of the tooth cavity - the presence of a shadow of filling material, instruments, denticles;

· condition of roots: number, shape, size, contours;

· characteristics of root canals: width, direction, degree and quality of filling;

· assessment of the periodontal gap: uniformity, width;

· condition of the compact plate of the socket: preserved, destroyed, thinned, thickened;

· condition of periapical tissues, analysis of the pathological shadow, determination of its location, shape, size and nature of the contour;

· assessment of surrounding tissues: condition of interdental septa – height, condition of the compact endplate.

Example:

On intraoral x-rays satisfactory quality:

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

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

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

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

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

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

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

Based on the data of the conducted clinical examination and the results of additional research methods are formulated diagnosis . Accordingly, the column "diagnosis" in the medical record is filled in only after full examination patient.

When making a diagnosis, it is necessary to highlight:

· main disease of the dental system and complication of the main disease;

· concomitant dental diseases;

· general concomitant diseases.

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

When formulating the main diagnosis, the first thing to distinguish is morphological changes dental system with indication etiological factor(For example, partial defect of the coronal part of the 46th tooth of carious origin).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

· refilling of root canals;

Depulpation of teeth planned for orthopedic design(for example, if it is necessary to radically prepare teeth with a wide cavity, when tilting or vertical movement of teeth);

· preparation of root canals for pin structures (unsealing of root canals).

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

· anatomical shape of the tooth crown;

· unity of dentition;

· lost functions and aesthetics.

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

Example:

“Restore the anatomical shape of the coronal part

tooth 16 – cast all-metal crown;

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

pin tabs;

tooth 21 – metal-ceramic crown;

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

If necessary special training tooth for prosthetics, planned activities should also be described in detail in the column "Treatment plan."

Example:

1. In order to eliminate deformation of the occlusal surface of the dentition of the upper jaw, it is recommended to depulpate the 16th tooth, followed by its grinding (shortening) and restoration of its shape with a cast all-metal crown.

2. Restore the anatomical shape of the crown of the 13th tooth with a cast stump pin and a metal-ceramic crown with preliminary preparation of the root canal for the cast stump pin (unsealing 2/3 of the length).

3. Restore the anatomical shape of the coronal part of the 11th tooth with a cast stump pin and metal-ceramic crown with preliminary revision, refilling and preparation of the root canal for the cast stump pin.

4. Restore the anatomical shape of the coronal part of the 21st tooth with a metal-ceramic crown with preliminary refilling of the root canal using a fiberglass pin.

5. Restore the anatomical shape of the crown of the 46th tooth with a cast stump pin insert and a cast all-metal crown with preliminary depulpation of the tooth and preparation of channels for the cast stump pin insert.

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

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

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

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

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

Orthopedic treatment was carried out ___________________________________

____________________________________________________________

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

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

IV. SAMPLES OF COMPLETING A DENTAL PATIENT'S MEDICAL CARD WHEN TREATING MAIN DENTAL DISEASES

OPTIONS FOR RECORDING THE ILLNESS HISTORY OF PATIENTS WHO HAVETOOTH EXTRACTION AND OTHER SURGICAL MANIPULATIONS PROVIDED

Exacerbation of chronic periodontitis

Complaints of pain in the upper jaw on the left, pain at 27 when biting.

History of the disease. 27 was previously treated, periodically bothered. Two days ago, 27 fell ill again, pain appeared in the area of ​​the upper jaw on the left, the pain when biting on 27 increases. History of influenza.

Local changes. There is no change during external examination. The submandibular lymph nodes are slightly enlarged on the left, painless on palpation. The mouth opens freely. In the oral cavity: 27 under a filling, the color is changed, its percussion is painful. In the area of ​​the apex of the roots 27, a slight swelling of the mucous membrane of the gums on the vestibular side is detected; palpation of this area is slightly painful. On radiograph 27, the palatal root is sealed to the apex, the buccal roots are sealed to 1/2 of their length. At the apex of the anterior buccal root there is a loss of bone tissue with unclear contours.

Diagnosis: “exacerbation of chronic periodontitis of the 27th tooth.”

a) Under tuberal and palatal anesthesia with 2% no-vocaine solution - 5 mm or 1% trimecanna solution - 5 mm plus 0.1% adrenaline hydrochloride - 2 drops (or without it), extraction was performed (specify tooth), socket curettage; the hole filled with a blood clot.

b) Under infiltration and palatal anesthesia (anaesthetics, see the entry above, indicate the presence of adrenaline), removal (18, 17, 16, 26, 27, 28) was performed, curettage of the hole; the hole filled with a blood clot.

c) Under infiltration and palatal anesthesia (anaesthetics, see the entry above, indicate the presence of adrenaline), removal was performed (15, 14, 24, 25). Curettage of the socket(s), the socket(s) became filled with blood clot(s).

d) Under infraorbital and palatal anesthesia (see anesthetics above, indicate the presence of adrenaline), removal was performed ( 15, 14, 24, 25).

e) Under infiltration and incisive anesthesia (see anesthetics 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 incisal anesthesia (see anesthetics 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.

Acute purulent periodontitis

Complaints of pain in the area of ​​32, radiating to the ear, pain when biting on 32, a feeling of an “overgrown” tooth. General condition is satisfactory; past diseases: pneumonia, childhood infections.

History of the disease. About a year ago, pain first appeared at 32, and was especially bothersome at night. The patient did not see a doctor; gradually the pain subsided. About 32 days ago the pain reappeared; consulted a doctor.

Local changes. There are no changes upon external examination. The submental lymph nodes are slightly enlarged and 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 and swollen. There are no changes on X-ray 32.

Diagnosis: “acute purulent periodontitis 32.”

a) Under mandibular and infiltration anesthesia (see anesthetics above, indicate the presence of adrenaline), removal of (specify tooth) 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38 was performed; curettage of the holes, they are compressed and filled with blood clots.

b) Under torusal anesthesia (see anesthetics above, indicate the presence of adrenaline), removal of 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38 was performed.

Curettage of the hole, it is compressed and filled with a blood clot.

c) Under bilateral mandibular anesthesia (see anesthetics above), removal of 42, 41, 31, 32 was performed. Curettage of the socket, it was compressed and filled with a blood clot.

d) Under infiltration anesthesia (see anesthetics 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 right cheek, pain in this area, increased body temperature.

Previous and concomitant diseases: duodenal ulcer, colitis.

History of the disease. Five days ago pain appeared at 13; two days later, swelling appeared in the gum area, and then in the cheek area. The patient did not consult a doctor; he applied a heating pad to his cheek, took warm intraoral soda baths, and took analgia, but the pain grew, the swelling increased, and the patient consulted a doctor.

Local changes. An external examination reveals a violation of the facial configuration due to swelling in the buccal and infraorbital areas on the right. The skin over it is not changed in color, it folds painlessly. The submandibular lymph nodes on the right are enlarged, compacted, and slightly painful on palpation. The mouth opens freely. In the oral cavity: 13 - the crown is destroyed, its percussion is moderately painful, mobility is II – III degree. Pus is released from under the gingival margin. The transitional fold in the area 14, 13, 12 bulges significantly, is painful on palpation, and fluctuation is detected.

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, spreading to the upper part of the submental area; sharp pain 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 undergo treatment; he went to the clinic on the 4th day of the disease.

Previous and concomitant diseases: influenza, sore throat, penicillin intolerance.

Local changes. During an external examination, swelling of the lower lip and chin is determined; its soft tissues are not changed in color and are folded freely. The submental lymph nodes are slightly enlarged and slightly painful on palpation. Opening the mouth is not difficult. In the oral cavity: the transitional fold in the area of ​​42, 41, 31, 32, 33 is smoothed, its mucous membrane is swollen and hyperemic. Palpation reveals a painful infiltrate in this area and a positive symptom of fluctuation. Crown 41 is partially destroyed, percussion is slightly painful, mobility is grade I. Percussion of 42, 41, 31, 32, 33 is 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 (see the anesthetic 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

(specify within which teeth) 3 cm (2 cm) long to the bone. Pus was obtained. The wound was drained with a rubber strip. Prescribed (indicate medications prescribed to the patient and their dosage).

The patient is incapacitated from _______ to _________, sick leave No. ______ has been issued. Appearance ______for dressing.

Diary entry after opening a subperiosteal abscess in acute purulent periostitis of the jaw

The patient's condition is satisfactory. There is an improvement (or worsening, or no change). The pain in the jaw area has decreased (or increased, remains the same). The swelling of the perimaxillary tissues has decreased, and 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 furatsilin at a dilution of 1:5000. A rubber strip is inserted into the wound (or the wound is drained with a rubber strip)

Complaints of pain in the area of ​​the hard palate on the left of a pulsating nature and the presence of swelling on the hard palate. The pain intensifies when touching the swelling with the tongue.

History of the disease. Three days ago, pain appeared in the previously treated 24, pain when biting, and a feeling of an “overgrown 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: stage II hypertension, cardiosclerosis.

Local changes. Upon external examination, the facial configuration was not changed. Palpation reveals an increase in the submandibular lymph nodes on the left, which are painless. Mouth opening freely. In the oral cavity: on the hard palate on the left, respectively 23 24 there is an opal-shaped bulge with fairly clear boundaries, the mucous membrane above it is sharply hyperemic. Fluctuation is determined at its center. 24 - the crown is partially destroyed, there is a deep carious cavity. Percussion of the tooth is painful, tooth mobility is grade I.

Diagnosis: “acute purulent periostitis of the upper jaw on the palatal side to the left (palatal abscess) from the 24th tooth.”

Under palatal and incisal anesthesia (specify the anesthetic and the addition of adrenaline), the abscess of the hard palate was opened with excision of soft tissue to the bone in the form of a triangular flap within the entire infiltrate, and pus was obtained. The wound was drained with a rubber strip. Drug therapy was prescribed (specify which).

The patient is incapacitated from _______ to _______., sick leave No. _______ was issued. Show up _________for dressing.

Acute purulent osteomyelitis

Complaints of shooting, boring pain in the area of ​​the entire half of the lower jaw on the right, severe weakness, increased body temperature up to 39ºC, chills, sweating, bad smell from mouth.

The patient has no previous 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 a chill at night. In the morning I went to the doctor. The tooth was removed. There was no improvement. Pain in the jaw and general weakness increased; There was numbness in the skin of the lower lip on the right, and bad breath. The swelling of the soft tissues increased, and the body temperature increased.

Local changes. An external examination reveals significant swelling in the submandibular and cheek areas on the right; the skin above it is hyperemic, tense, and does not fold. Palpation of tissue 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 of ​​48, 47, 46, 45 on the vestibular and lingual sides is swollen and hyperemic. Percussion of 47, 45 is sharply painful, the teeth are mobile. A bulge is detected along the transitional fold in the area of ​​48, 47, 46, 45 on the vestibular side, and infiltration of the soft tissues of the alveolar process in the area of ​​these teeth on the lingual side. Pus is released from hole 46.

Diagnosis: “odontogenic acute purulent osteomyelitis of the lower jaw on the right, inflammatory infiltrate of the submandibular and buccal areas on the right.”

Under torusal anesthesia (specify the anesthetic), an incision was made along the transitional fold to the bone in the area 47, 46, 45, 44, pus was obtained, and an incision was made in the area of ​​the alveolar or sprout on the lingual side (to the bone) within these teeth, no pus was obtained, stagnant blood was obtained. The wounds are drained with rubber strips. Drug therapy was prescribed (specify which). The patient is incapacitated from _______ to _______, sick leave No. ______ has been issued. Turning up________for dressing.

Odontogenic cystogranuloma

Complaints of periodic pain in 11. The tooth was previously treated with canal filling. Considers himself practically healthy.

Local changes. Upon external examination, the facial configuration is not disturbed. The submandibular and parotid lymph nodes are not palpable. The mouth opens freely. In the oral cavity: the mucous membrane is pale pink in color, well moisturized. When palpating the alveolar part of the upper jaw from the vestibular side, a slight bulge is detected in the area of ​​​​the projection of apex 11. On the radiograph in the area of ​​apex 11 there is a rarefaction of bone tissue of a round shape with clear contours with a diameter of 0.6 cm. Canal 11 is sealed with cement by 2/3.

Diagnosis: cystogranuloma in area 11.

Recording of apex resection operation

Under conduction (specify which) and infiltration anesthesia (specify the anesthetic and adrenaline solution, if one was used), a semi-oval (or trapezoidal) soft tissue incision was made from the alveolar process to the bone. A flap is formed with its base facing the transitional fold. The mucoperiosteal flap has been detached in the area of ​​(specify the formula of the teeth). An abnormality was detected in the compact plastic of the alveolar process (if there was one), which was expanded with a bur. The root apex with granuloma was isolated, the root apex was resected (specify the tooth formula) using a fissure bur, which was removed with a curettage spoon along with the cystogranuloma. The protruding part of the root is smoothed with a milling cutter to the bottom of the bone cavity. The wound was washed with a solution of furatsilin 1:5000 and a solution of 0.05% chlorhexidine. The flap is placed in place and fixed with catgut sutures. A pressure bandage is applied. Drug therapy was prescribed (specify which).

The patient is incapacitated from _____ to __________, sick leave No. ______ has been issued.

Turnout________for bandaging.

Semi-retention and dystopia of teeth

Complaints of periodic pain in the lower jaw area on the left and difficulty opening the mouth. Past and concomitant diseases: influenza, penicillin intolerance.

History of the disease. He considers himself sick for about 1 year. In January 2008 For the first time I felt the appearance of painful swelling of the gums in the area 37 and some difficulty opening my mouth. I went to the district clinic, where treatment was carried out: 5 sessions of UHF therapy on the area of ​​the angle of the lower jaw, took norsulfazole orally, took baths with baking soda. The above phenomena subsided. Sent for consultation to the regional clinical dental clinic.

Local changes. Upon external examination, the configuration of the face is not disturbed; palpation reveals an enlarged (1 cm in diameter), painless, mobile submandibular lymph node on the left. Opening the mouth is free and painless. In the oral cavity: the mucous membrane of the vestibule of the mouth is pale pink, sufficiently moist. 38 is cut through by two distal tubercles, displaced towards 37.

On the radiograph, crown 38 is displaced anteriorly, with its medial tubercles adjacent to root 37.

Diagnosis: “semi-retention and dystopia 38.”

Recording of tooth extraction with flap

Under infiltration or conduction (in this case, indicate which) anesthesia (see anesthetic above), an angular (or trapezoidal, semi-oval) incision was made and the mucoperiosteal flap 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

(specify within which teeth). A compact plate of alveolar bone tissue was trepanned with a bur in the area of ​​(specify the formula of the tooth being removed) on the vestibular side (when removing 48, 38 - additionally in the retromolar area). The bone tissue was removed with a bur.

The tooth was dislocated with an elevator and removed with forceps. The wound was washed with a 3% solution of hydrogen peroxide, and honsuride (oxycelodex, hydroxyapatite, hemostatic sponge). The flap is placed in place, the wound is sutured with catgut sutures. A pressure bandage is applied.

The patient is incapacitated from ________ to ______, sick leave No. _________ has been issued. Drug therapy was prescribed (specify which).

Retention cyst of the oral mucosa

Complaints about the formation of a spherical shape in the mucous membrane of the lower lip. Previous and concomitant diseases: flu, sore throat.

History of the disease. About 3 months ago, the patient bit his lower lip while eating. A few days after this, I noticed the appearance of a small formation in the thickness of the lip, which gradually enlarges, does not hurt, but interferes with eating. I went to the doctor.

Local changes. Upon external examination, the facial configuration was not changed. Regional lymph nodes are not palpable. Opening the mouth is free and painless. In the oral cavity: the mucous membrane is pale pink in color, sufficiently moist. On inner surface of the lower lip on the right, a rounded neoplasm with a diameter of 0.7 cm is detected, different in color from the surrounding mucous membrane. On bimanual palpation, the thickness of the lower lip is determined to be round in shape, formation, soft-elastic consistency, painless, mobile.

Diagnosis: “retention cyst of the lower lip.”

Record of the operation to remove a retention cyst of the lower lip

Under infiltration anesthesia (specify anesthetic), the mucous membrane of the lip was dissected with two semi-oval converging incisions. Bluntly and acutely, the retention cyst is isolated from the surrounding tissues, hemostasis. The wound is sutured with catgut sutures. A pressure bandage is applied. The removed specimen was sent for histological examination.

The patient is incapacitated from _______ to ___________, sick leave No. ______ has been issued. Showing up___________ for dressing.

Tongue papilloma

Complaints about a tumor on the tip of the tongue. Previous and concomitant diseases: stage II hypertension.

History of the disease. The patient noticed the appearance of a tumor 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 tumor.

Local changes. During an external examination, no violation of the facial configuration was noted. Regional lymph nodes are not palpable. Opening the mouth is free and painless. In the oral cavity: the mucous membrane is pale pink, well moisturized. At the tip of the tongue there is a neoplasm measuring 0.5 cm, on a narrow stalk. On palpation - soft, painless, mobile. On the mucous membrane of the neoplasm there are fringed outgrowths that are barely noticeable upon examination.

Diagnosis: tongue papilloma.

Recording the excision operation benign neoplasm(papilloma, fibroma, etc.)

Under infiltration anesthesia (specify anesthetic), two semi-oval converging incisions were used to excise the neoplasm of the mucous membrane (specify organ) within healthy tissues to the muscle layer. The wound was sutured with catgut sutures, and the removed tumor was sent for histological examination.

The patient is incapacitated from ________ to _______, sick leave No. ______ has been issued. Show up ________for dressing.

Radicular cyst of the jaw

Example 11.

Complaints of a painless swelling in the upper jaw area on the left, raising the upper lip.

Previous and concomitant diseases: the patient is practically healthy.

History of the disease. Previously, 22 was periodically ill, but the patient did not see a doctor. I noticed the swelling about 2 years ago. I noticed its gradual increase. Currently, due to a cosmetic defect, he has been referred for consultation to a regional clinical dental clinic.

Local changes. On external examination, there is a slight swelling of the upper lip on the left. The skin under the swelling is of normal color, folds well, and upon palpation the tissues are soft and painless. Regional lymph nodes are not palpable. Opening the mouth is free and painless. The base of the lower nasal meatus on the left is elevated (Gerberian ridge). In the oral cavity: the mucous membrane is pale pink in color, sufficiently moist. A limited semi-oval swelling is detected on the vestibular side of the alveolar part of the upper jaw in the area of ​​11, 21, 22, 23 teeth. The mucous membrane over the swelling is pale with a pronounced vascular pattern. On palpation, the swelling is pliable, moderately dense, painless. In its center there is a mild symptom of parchment crunching. The crowns of teeth 21 and 22 converge, 21 is discolored, percussion is painless.

Dental formula:

An x-ray of the alveolar process of the upper jaw reveals rarefaction of bone tissue in the area 11,21,2 2,23 teeth with smooth and clear contours of a rounded shape. The area of ​​bone loss extends to the bottom of the nose. EDI was carried out: 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 back the bottom of the nose.”

Cystectomy surgery recording

The roots of teeth whose apical resection is performed are pre-filled with phosphate cement during the operation. Under conduction (specify which) and infiltration anesthesia (specify anesthetic), a semi-oval (or trapezoidal) incision was made in the mucous membrane from the periosteum to the bone. A flap is formed with its base facing the transitional fold so that the future bone wound is slightly smaller than the soft tissue flap. A mucoperiosteal flap is peeled off in the area (indicate which teeth).

An usura was found in a thinned and swollen compact plate of the alveolar process bone, which was expanded in pieces until the anterior wall of the cyst shell was completely exposed. The shell of the radicular cyst was discovered and completely isolated, the apexes of the roots were resected (specify dental formula), which are removed along with the shell of the radicular cyst. The sharp edges of the resulting cavity are smoothed with a milling cutter to ensure hemostasis and toilet surgical wound and mucoperiosteal flap. If necessary, the postoperative bone cavity is filled with hemostatic, replacement or optimizing reparative osteogenesis drugs. The flap is placed in place, the wound is sutured with catgut sutures. A pressure bandage is applied. The material was sent for histological examination.

The patient is incapacitated from _______ to __________, sick leave certificate No. __________ has been issued. Drug therapy was prescribed (specify).

Recording of 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 has been detached in the area of ​​(specify the formula of the teeth). A bone lesion was discovered, which was expanded with a bur and pliers 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 a 3% hydrogen peroxide solution. Muco-

the periosteal flap is placed in the cavity of the cyst, into which an iodoform tampon is tightly inserted in layers, fixing the flap (or the edge of the mucoperiosteal flap is sutured to the shell of the cyst). A pressure bandage is applied. The material was sent for histological examination.

The patient is incapacitated from _______ to _____________, sick leave No. ______ has been issued. Drug therapy was prescribed (specify which). Appearance _________ for dressing.

Date of_______________

Complaints: no, for quickly passing pain when eating sweet, cold food in the _______ tooth, I contacted him for the purpose of sanitation.

Anamnesis: ____the tooth was not previously treated, was previously treated for caries, the filling fell out (partially), I noticed the cavity on my own, during an examination _____ days (week, month) ago, I did not seek help.

Objectively: facial configuration is not changed, skin clean, regional lymph nodes are not enlarged. The mouth opens freely. The mucous membrane of the oral cavity is pale pink and moist. On the medial, distal, vestibular, oral, chewing surface(s)______ of the tooth, a carious cavity of medium depth, filled (partially filled) with softened pigmented dentin, filling material. Probing is painful along the enamel-dentin border, percussion is painless, the reaction to temperature stimuli is painful and passes quickly. GI=___________.

D.S. : Average caries of _______ tooth. Black class _________.

Treatment: Psychological preparation to treatment. Under anesthesia, without anesthesia, preparation of a carious cavity (removal of a filling), medicinal treatment with a 3.25% sodium hypochlorite solution, rinsing, drying._______________________ Isolating pad ________________Filling______________________. Grinding. Polishing.

Seal insulation: Vaseline, Axil, varnish.