Documente Academic
Documente Profesional
Documente Cultură
Endodontie
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
tulburri masticatorii
sngerare gingival continuare tratament (control)
tulburri fizionomice
consult interdisciplinar
ANTECEDENTE PERSONALE
ANTECEDENTE PERSONALE GENERALE
nesemnificative
semnificative
Meniuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________
temporizeaz tratamentul
necesit spitalizare
Meniuni: _____________________________________________________________________________________________________________
______________________________________________________________________________________
finalizate
nefinalizate
Tratamente parodontale:
rare
multiple
de ntreinere
chirurgicale
Tratamente protetice
conjunct
adjunct
satisfctoare
nesatisfctoare
Tratamente ortodontice:
aparate fixe
aparate mobile
satisfctoare
nesatisfctoare
Anul ______
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
Evoluie
lent
rapid
Tratamente efectuate
eficiente
ineficiente
inspecie
palpare
Structuri osoase:
inspecie
palpare
Puncte trigeminale:
inspecie
palpare
Ganglioni:
inspecie
ATM:
inspecie
palpare
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: _____________________________________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
2
Pacient _____________________
Nr. fi _____________________
Medic _____________________
Student _____________________
Dinte ______
SEMNE SUBIECTIVE
DUREREA
Tip i intensitate:
Durata:
Apariie:
provocat
spontan
Amendare:
Localizare:
jen
violent
pe durata excitantului
zeci de minute / ore
medie
pulsatil
minute 1 - 10
episoade / crize
vie
lancinant
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
permanent
SENZAIA DE EGRESIUNE
absent
prezent
absent
prezent
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
HALENA FETID
SEMNE OBIECTIVE
INSPECIE
Coroana
Coroana:
Rdcina:
expus
neexpusa
pung parodontal prezent pung parodontal absent
Mucoasa alveolar:
aspect normal
tumefacie
congestie
fistul
edem
nodul
o
o
oral
vestibular
o
o
activ
cicatrizat
PALPARE
Dinte
Dentin
dur
ramolit
Spaiu de percolare
prezent
absent
Mobilitate obturaie
prezent
absent
Sensibilitate dureroas
marginile cavitii
fundul cavitii
camera pulpar
canal radicular
Sngerare
papila interdentar
Secreii intracanalare
Mobilitate
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
accentuat
fluctuent
prezent
renitent
absent
crepitaii
PERCUIA
Percuia n ax
negativ
uor pozitiv
intens pozitiv
Percutia transversala
negativ
uor pozitiv
intens pozitiv
normal
mat
AUSCULTAIE
Sunet
TESTE DE VITALITATE
TIPUL TESTULUI DE VITALITATE
electric
termic la cald
termic la rece
foraj explorator
hipoexcitabilitate
negative
hiperexcitabilitate
EXAMENE RADIOGRAFICE
Tratament endodontic
Corect
Incorect
Pivot radicular
Cai false
da
subdimensionat
neetan
nu
supradimensionat
neobturat
prefabricat
prezente
turnat
absente
Corpi strini
prezeni
abseni
Pulpolii
prezeni
abseni
Morfologie canalar
favorabil tratamentului
nefavorabil tratamentului
Periapical
Normal
1 5 mm
Radiotransparen
5 10 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:...............................................................................................................................................................
............................................................................................................................................................................
Biopulpectomie
Debridare mecano-chimica
Tratament medicamentos
Obturare radiculara definitiva
Interventie chirurgicala
Reconstituire coronara
Reconstituire corono-radiculara
Monitorizarea pacientului
MANOPERE EFECTUATE
Nr.
crt.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Manopere
Manopere
necesare
Data
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
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,
____________________