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Facultatea de Medicin Dentar Constana

Disciplina DIAGNOSTIC ORO-DENTAR SI ERGONOMIE


Student_________________________
Cadru Univ. dr.______________________

FI DE CONSULTAIE

Nr.__________.Data__________

1. Anamneza:
a. Numele i prenumele________________________________ CNP________________
b. Vrsta_____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. ____________________________________

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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: ______________________________________________________

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Amplitudinea deschiderii gurii, excursia mentonului, devieri
Palpare: ___________________________________________________________________
Ascultaie: ________________________________________________________________
(zgomote la deschidere, intermediare, la nchidere)

b. Endobucal:
Examen oncologic preventiv: ___________________________________________________
___________________________________________________________________________
Mucoase: jugal, palatinal, lingual _____________________________________________
Limba ________________________________ Frenuri ______________________________

Abraziune/atritie

Hiperplazie

Hipertrofie
gingival
Congestie /
staz
Migrri
secundare

Edentaii

Hiperestezie

Lacune
cuneiforme

Leziuni carioase

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

Leziuni carioase

Lacune
cuneiforme

Hiperestezie

Edentaii

Migrri
secundare
Congestie /
staz
Hipertrofie
gingival

Hiperplazie

Abraziune/atritie

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Analiza ocluzal: contacte premature n RC/IM:_____________________________________
interferene n: propulsie: ________________________________________
lateralitate: _______________________________________
parafuncii: bruxism, ncletarea dinilor ____________________________
ANALIZA OCLUZIEI STATICE

M dr C dr I 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 urgen_____________________________________________________
odontal ___________________________________________________________
chirurgical_________________________________________________________
protetic ___________________________________________________________
ocluzie____________________________________________________________

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ortodontic _________________________________________________________
-parodontal_________________________________________________________
ATM______________________________________________________________
functional_________________________________________________________
evolutiv___________________________________________________________
3. 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______________

EXAMENUL IGIENEI ORALE

Plan de tratament
___________________________________________________________________________
___________________________________________________________________________
5
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___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________

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