Facultatea de Medicin Dentar Constana

Disciplina de diagnostic oro-dentar si ergonomie

Student__________________________________Cadru Univ. dr.______________________
FI DE CONSULTAIE
Data ___________________
1. Anamneza:
a. Numele i prenumele:
b. Vrsta

ani

CNP________________

Sexul_____ Adresa__________________________________

Tel._______________ Profesia___________.
c. Motivele prezentrii_____________________________________________________
_____________________________________ trimis de_______________________________
d. Antecedente personale fiziologice__________________________________________
Grupa sangvin_____ Tip constituional__________ Tipul sistemului nervos
(echilibrat / neechilibrat) Condiii de via i de munc _________________________
Tipul alimentaiei (diet, alimente preferate, consisten, felul masticaiei)__________
___________________________________________________________________________
e. Antecedente heredo-colaterale dentare ______________________________________
f. Antecedente heredo-colaterale sistemice ____________________________________
g. Istoricul afeciunilor dentare (debut, evoluie, tratament) _______________________
___________________________________________________________________________
h. Anamneza sistemic:
Afeciuni virale: hepatit epidemic, HIV, poliomielit, .a.___________________________
Afeciuni bacteriene: pneumonii, tuberculoz pulmonar, RAA, .a.____________________
Afeciuni cardio-vasculare: congenitale, HTA_____________, aritmii, cardiopatie ischemic,
infarct miocardic (cnd, cte)____________, valvulopatii, flebite, .a.___________________
Afeciuni sangvine: leucemie acut/cronic, agranulocitoz, anemie feripriv / pernicioas /
hemolitic, leucopenie, trombocitopenie, coagulopatii, sindroame hemoragice .a.
___________________________________________________________________________
Afeciuni respiratorii: sinuzite, bronite, astm bronic ________________________________
Afeciuni digestive: leziuni precanceroase ale cavitii bucale, disfagie, gastrit, ulcer gastric /
duodenal, colecistit, pancreatit, apendicit .a. ____________________________________
Afeciuni metabolice: diabet zaharat insulino-dependent / non-insulino-dependent, obezitate,
dislipidemii, rahitism, hipocalcemie, hipovitaminoze, osteoporoz ____________________
Afeciuni ale sistemului nervos: nevralgii, migrene, epilepsie, schizofrenie, nevroze________

Afeciuni endocrine: hipertiroidism, hipotiroidism, hiperparatiroidism, hipoparatiroidism,

nanism hipofizar, acromegalie, hipercorticism, hipocorticism__________________________
Afeciuni uro-genitale: IRA, infecii urinare, cistit, nefrit, litiaz renal, menopauz,
amenoree, infecii venerice-lues, gonoree _________________________________________
Afeciuni locomotorii: spondilit reumatoid / ankilopoetic, distrofii musculare __________
Afeciuni ale tegumentelor i mucoaselor: infecii cutanate, micoze, dermatite, psoriazis,
lichen plan, leucoplazie, erizipel .a.______________________________________________
Alergii: alimentare, medicamentoase-sulfamide, antibiotice, anestezice, ZnCl2, Iod .a.
___________________________________________________________________________
Tratamente medicamentoase ____________________________________________________
2. Examen obiectiv
a. Exobucal:
Inspecie:
Norm Frontal (simetrie, proporia etajelor, anuri peri orale)
___________________________________________________________________________
Aspectul tegumentelor ________________________________________________________
Norm Lateral ______________________________________________________________
Obiceiuri vicioase: respiraie oral, mixt, deglutiie infantil, interpoziia limbii / obiecte
ntre dini, onicofagie s.a.: ______________________________________________________
Palpare: Adenopatie: localizare____________________ sensibilitate ___________________
____________, aderen ______________________, consisten ______________________
Contururi osoase_____________________________________________________________
Muchi masticatori ___________________________________________________________
Palpare puncte sinusale ________________________________________________________
Palpare puncte de emergen trigeminale __________________________________________
Examen ATM: Inspecie: ______________________________________________________
Amplitudinea deschiderii gurii, excursia mentonului, devieri
Palpare: ___________________________________________________________________
Auscultaie: ________________________________________________________________
(zgomote la deschidere, intermediare, la nchidere)
b.

Endobucal:

Examen oncologic preventiv: ___________________________________________________

___________________________________________________________________________
Mucoase: jugal, palatinal, lingual _____________________________________________
Limba ___________ Frenuri _____ Orificii canale salivare

Abces
parodontal
Abces
periapical
Resturi
radiculare
Hiperplazie
gingival
Congestie /
staz
Migrri
secundare
Edentaii
Hiperestezie
Lacune
cuneiforme
Leziuni carioase
Obturatii
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

Obturatii
Leziuni carioase
Lacune
cuneiforme
Hiperestezie
Edentaii
Migrri
secundare
Congestie /
staz
Hiperplazie
gingival
Resturi
radiculare
Abces
periapical
Abces
parodontal

EXAMEN GINGIVOPARODONTAL
1. PROTOCOL IN EXAMINAREA GINGIVALA
A. Examinarea inflamatiei gingivale
a. Sangerare:
b. Modificari de culoare:

c. Tumefactie:
d. Aspect:
e. Consistenta:
B. Indicii de inflamatie
Indicele de placa
Indicele de tartru
Indicele de igiena orala:
Indicele de sangerare
Indicele gingival
2. PROTOCOL IN EXAMINAREA PARODONTALA
1. Inflamatie;
2. Mobilitate dentara; in grade
3. Retractie gingivala;
4. Afectarea furcatiei; in grade
5. Punga parodontala.
Analiza ocluzal: contacte premature n RC/IM:_____________________________________
interferene n: propulsie: ________________________________________
lateralitate: _______________________________________
abraziune: ____________________________________________________
ANALIZA OCLUZIEI STATICE
M dr

C dr

C stg

M stg

Plan sagital
Plan transversal
Plan vertical
ANALIZA OCLUZIEI DINAMICE
Conducere
Lateralitate dreapta

Parte lucratoare
Parte nelucratoare
Conducere

Lateralitate stanga

Parte lucratoare
Parte nelucratoare
Conducere

Propulsie

Interferente dr
Interferente stg

Anomalii: dento-maxilare:n plan sagital, transversal, vertical: _________________________

dento-alveolare:incongruen cu nghesuire/spaiere:_________________________

dentare izolate:numr,volum,form,poziie,erupie,structur: __________________

Diagnostic: de urgenta_________________________________________________________
odontal ___________________________________________________________
chirurgical_________________________________________________________
protetic ___________________________________________________________
parodontal__________________________________________________________
ocluzie____________________________________________________________
ortodontic _________________________________________________________
ATM______________________________________________________________
functional_________________________________________________________
evolutiv___________________________________________________________
Circumstane etiopatogenice generale i locale: _____________________________________
___________________________________________________________________________
3. Examene complementare:
Analize de laborator: hematologice: hemoleucograma, VSH, TS, TC, TH, TQ
Analize biochimice: glicemie, calcemie, transaminaze, electroforeza, creatinina, acid uric,
lipide totale, colesterol, trigliceride, examen de urin:_______________________________
Examen cito-bacteriologic_____________________________________________________
Examene medicale de specialitate _______________________________________________
Examene imagistice: RX _______________________________________________________
Modele de studiu________________
Fotografii______________
STATUSUL IGIENEI ORALE NAINTE DE TRATAMENT

Plan de tratament
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Sunt de acord cu tratamentul efectuat n acest cabinet.
Tratamente efectuate

Semntura,
Data