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Fisa Observatie Endodontie
Fisa Observatie Endodontie
POPA IAI
FACULTATEA DE MEDICIN DENTAR
FOAIE DE OBSERVAIE
- ENDODONIE DATE GENERALE
Nume:
Vrsta :
Adresa:
Tel. fix:
Loc munc:
______________________
Prenume:
______________________
______________________________________
______________________
Tel. mobil:
______________________
Ocupaie:
______________________
______________________
______________________
______________________
MOTIVELE PREZENTRII
durere
sngerare gingival
tulburri masticatorii
continuare tratament (control)
tulburri fizionomice
consult interdisciplinar
ANTECEDENTE PERSONALE
ANTECEDENTE PERSONALE GENERALE
nesemnificative
semnificative
Meniuni:
____________________________________________________________________________________________
_________________
______________________________________________________________________________________
temporizeaz tratamentul
necesit spitalizare
Meniuni:
____________________________________________________________________________________________
_________________
______________________________________________________________________________________
Tratamente odontale:
rare
multiple
finalizate
nefinalizate
Tratamente parodontale:
rare
multiple
de ntreinere
chirurgicale
Tratamente protetice
conjunct
adjunct
satisfctoare
nesatisfctoare
Tratamente ortodontice:
aparate fixe
satisfctoare
Tratamente chirurgicale OMF: Anul ______
aparate mobile
nesatisfctoare
Tipul: _________________________________________
Meniuni:
____________________________________________________________________________________________
_________________
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
1
Debut
acut
insiduos
2
Evoluie
lent
rapid
Tratamente efectuate
eficiente
ineficiente
inspecie
palpare
Structuri osoase:
inspecie
palpare
Puncte trigeminale:
inspecie
palpare
Ganglioni:
inspecie
palpare
ATM:
inspecie
palpare
Meniuni:
____________________________________________________________________________________________
_________________
______________________________________________________________________________________
______________________________________________________________________________________
inspecie
palpare
Vestibul maxilar
inspecie
palpare
Vestibul mandibular
inspecie
palpare
Mucoas palatin
inspecie
palpare
Limb
inspecie
palpare
Planeu
inspecie
palpare
inspecie
palpare
inspecie
palpare
Parodontiu
inspecie
palpare
Meniuni:
____________________________________________________________________________________________
_________________
________________________________________________________________________________________
____________________________________________________________________________________
EXAMENUL OCLUZIEI
Modificri ale ocluziei ___________________________________________________________________
________________________________________________________________________________________
____________________________________________________________________________________
Meniuni:
____________________________________________________________________________________________
_________________
______________________________________________________________________________________
OGLINDA DENTAR
Meniuni:
____________________________________________________________________________________________
_________________
________________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________________________
____________________________________________________________________________________
Pacient _____________________
Nr. fi _____________________
Medic _____________________
Student _____________________
Dinte ______
SEMNE SUBIECTIVE
DUREREA
Tip i intensitate:
Durata:
Apariie:
provocat
spontan
Amendare:
Localizare:
jen
medie
violent
pulsatil
pe durata excitantului minute 1 - 10
zeci de minute / ore
episoade / crize
vie
lancinant
permanent
cald
acru
diurn
n episoade (crize)
spontan
ocluzie
localizat
rece
dulce
mecanic
frecvent nocturn
spontan
rece
cald
antialgice uzuale
iradiat
o dini vecini,
o hemiarcad,
o hemifacies,
o zone de vecintate
absent
prezent
absent
prezent
SENZAIA DE EGRESIUNE
HALENA FETID
SEMNE OBIECTIVE
INSPECIE
Coroana
Coroana:
integr
proces carios
obturatie provizorie
abraziune
obturaie definitiv
atriie
fractura
o cu deschiderea camerei pulpare
o fr deschiderea camerei pulpare
coroan de nveli
polip pulpar
o roz pal
o rou intens
Rdcina:
expus
neexpusa
pung parodontal prezent pung parodontal absent
Mucoasa alveolar:
aspect normal
tumefacie
o oral
o vestibular
congestie
fistul
o activ
o cicatrizat
edem
nodul
PALPARE
Dinte
Dentin
dur
ramolit
Spaiu de percolare
prezent
absent
Mobilitate obturaie
prezent
absent
Sensibilitate dureroas
marginile cavitii
fundul cavitii
Sngerare
Secreii intracanalare
Mobilitate
camera pulpar
canal radicular
papila interdentar
camera pulpar
exsudat purulent
coronar
canal radicular
sanguino-purulent
exsudat clar
corono-radicular
Mucoasa alveolar
Sensibilitate dureroas
moderat
Zona
indurat
Exprimare de secreie prin fistula
fluctuent
prezent
accentuat
renitent
absent
crepitaii
PERCUIA
Percuia n ax
negativ
uor pozitiv
intens pozitiv
Percutia transversala
negativ
uor pozitiv
intens pozitiv
termic la rece
foraj explorator
AUSCULTAIE
Sunet
normal
mat
TESTE DE VITALITATE
TIPUL TESTULUI DE VITALITATE
electric
termic la cald
hiperexcitabilitate
hipoexcitabilitate
negative
EXAMENE RADIOGRAFICE
Tratament endodontic
Corect
da
nu
Incorect
subdimensionat
neetan
supradimensionat
neobturat
Pivot radicular
prefabricat
Cai false
turnat
prezente
Corpi strini
absente
prezeni
Pulpolii
abseni
prezeni
Morfologie canalar
abseni
favorabil tratamentului
nefavorabil tratamentului
Periapical
Normal
Radiotransparen
5 10 mm
1 5 mm
> 10mm
preoperator
postoperator
la 6 luni
la 1 an
la 2 ani
Odontometrie: reper........................
Canal\mm
15
16
17
18
19
20
21
22
23
24
25
26
27
28
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
Mentiuni:..................................................................................................................................................................
.........................................................................................................................................................................
Interventie chirurgicala
Reconstituire coronara
Reconstituire corono-radiculara
5
Monitorizarea pacientului
MANOPERE EFECTUATE
Nr.
crt.
1.
2.
3.
4.
5.
6.
7.
Manopere
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Consultatie
Stabilire diagnostic
Stabilire plan de tratament
Educatie sanitara
Detartraj / Periaj profesional
Anestezie loco-regionala/plexala
Anestezie intrapulpara
Ablatie obturatie coronara/ coroana
invelis
Exereza dentinei alterata
Coafaj indirect/direct
Aplicare pansament calmant
Realizarea cavitatii de acces
Indepartarea pulpei coronare
Hemostaza
Indepartarea pulpei radiculare
Evidarea continutului camerei pulpare
Evidarea continutului canalar
Debridare mecano-chimica (EDTA)
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
8.
Manopere
necesare
Data
Pacient,
____________________
DATA
MANOPER (COD)
TARIF
SUBTOTAL
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,
____________________