Facultatea de Medicin Dentar Constana

Disciplina de parodontologie
Student_________________________
Cadru Univ. dr.______________________
FI DE CONSULTAIE
Nr._____ Data
1. Anamneza:
a. Numele i prenumele
b. Vrsta

BALAN

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 .a. ___________________
Afeciuni ale sistemului nervos: nevralgii, migrene, epilepsie, schizofrenie, nevroze. _______
Afeciuni endocrine: hipertiroidism, hipotiroidism, hiperparatiroidism, hipoparatiroidism,
nanism hipofizar, acromegalie, hipercorticism, hipocorticism .a. ______________________

Afeciuni uro-genitale: IRA, infecii urinare, cistit, nefrit, litiaz renal, menopauz,
amenoree, infecii venerice-lues, gonoree .a. ______________________________________
Afeciuni locomotorii: spondilit reumatoid / ankilopoetic, distrofii musculare .a.
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 care afecteaz parodoniul: hidantoin, nifedipin, ciclosporine,
anticoncepionale_____________________________________________________________
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
Abcesul
periradicular
Abces
parodontal
Formula dentara
M

OF

OM

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

Legenda: X - dinte extras; R rest radicular; C- carie; O- obturatie; M microproteza.

EXAMEN GINGIVOPARODONTAL
A. PROTOCOL IN EXAMINAREA GINGIVALA

EXAMINAREA INFLAMATIEI GINGIVALE:

1. SEMNE DE INFLAMATIE
a. Modificari de culoare:
b. Tumefactie:
c. Aspect:
d. Consistenta:
e. Fistule
2. INDICI DE INFLAMATIE
Indicele de placa
Indicele de tartru
Indicele de igiena orala:
Indicele de sangerare
Indicele gingival
3. FACTORI RETENTIVI DE PLACA (odontali, protetici, ortodontici)
4. SONDAJUL PUNGILOR FALSE ( In Gingivite Hiperplazice)
DINTE
Exemplu:11

V
2 mm

O
2 mm

5. RETRACTIA GINGIVALA
DINTE
11

V
5 mm

B. PROTOCOL IN EXAMINAREA PARODONTALA

1. EXAMINAREA INFLAMATIEI GINGIVALE:
1. SEMNE DE INFLAMATIE
2. INDICI DE INFLAMATIE
3. FACTORI RETENTIVI DE PLACA (odontali, protetici, ortodontici)
4. SONDAJUL PUNGILOR FALSE ( In Gingivite Hiperplazice)
DINTE
Exemplu:11

V
2 mm

O
2 mm

2. RETRACTIA GINGIVALA
DINTE
11

V
5 mm

4. AFECTAREA FURCATIEI; in grade

5. MOBILITATEA DENTARA; in grade
5. PUNGA PARODONTALA
DINTE

11

5+5=10 mm

2+7=9mm

11mm

5mm

Analiza ocluzal: contacte premature n

RC/IM:_____________________________________
interferene n: propulsie: ________________________________________
lateralitate: _______________________________________
abraziune: ____________________________________________________
parafuncii: bruxism, ncletarea dinilor ____________________________
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: odontal ___________________________________________________________
chirurgical_________________________________________________________
protetic ___________________________________________________________
ocluzie____________________________________________________________

ortodontic _________________________________________________________
ATM______________________________________________________________
functional_________________________________________________________
evolutiv___________________________________________________________
Circumstane etiopatogenice generale i locale: _____________________________________
Diagnostic parodontal____________________________________________________
Examene complementare:
Analize de laborator: hematologice: hemoleucograma, VSH, TS, TC, TH, TQ
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______________

STATUS PARODONTAL NAINTE DE TRATAMENT

Parodontometria

I
VI

CPITN
II
V

CODURI
COD 0= lipsa manifestarilor
COD 1= prezenta sangerarii
COD 2= tartru supragingival si subgingival;
COD 3= pungi parodontale 3,5-5,5 mmm;
COD 4= pungi parodontale peste 5,5 mm

III
IV
CLASE DE TRATAMENT
Clasa 0= cod 0
Clasa I= cod 1
Clasa II= cod 2+3
Clasa III= cod 4

PLAN DE TRATAMENT IN AFECTIUNI GINGIVOPARODONTALE

A. Plan de tratament in gingivite
A. EDUCATIE PENTRU SANATATEA ORODENTARA
1. Terapie antimicrobiana si antiinflamatorie
2. Terapie chirurgicala
3. Terapie de biostimulare
4. Terapia de mentinere

B. Plan de tratament in parodontite

A. EDUCATIE PENTRU SANATATEA ORODENTARA
1. Terapie antimicrobiana si antiinflamatorie
2. Terapie chirurgicala
3. Terapie de biostimulare
4. Terapie functionala
5. Terapia de mentinere

REEVALUARE DUPA TRATAMENT

CPITN
I
VI

II

III

IV

Sunt de acord cu tratamentul efectuat n acest cabinet.

Semntura,

Tratamente efectuate

Data