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-I rauUNIVERSITATEA DE MEDICIN I FARMACIE "GR. T.

POPA IAI
FACULTATEA DE MEDICIN DENTAR

 Student

 Nespecialist

Nr. fi: ________________


Medic: _________________
Sudent: ________________
 Specialist

 Primar

FOAIE DE OBSERVAIE
- PARODONTOLOGIE DATE GENERALE
Nume:
Vrsta :
Adresa:
Tel. fix:
Loc munc:

______________________
Prenume:
______________________
Sex
______________________________________
______________________
Tel. mobil:
______________________
Ocupaie:

______________________
______________________
______________________
______________________
______________________

Meniuni: _____________________________________________________________________________________________________________

MOTIVELE PREZENTRII
 sngerare gingival
 probleme estetice legate de recesiuni sau migrri
dentar
 tulburri masticatorii legate de mobilitate dentar
 halitoz, gust neplcut n cavitatea oral
 senzaie tensiune sau prurit la nivelul gingiei

 simptomatologie legat de complicaiile bolii


parodontale (abcese parodontale, parestezii,
sindrom endo-parodontal)
 probleme odontale (carii simple i complicate)
 probleme endodontice (durere cu caracterele
specifice)

ISTORICUL AFECIUNII PARODONTALE


Durat
Debut
Semne de debut
Evoluie
A mai fost tratat?

zile _______
luni _______
 lent
 provocat
 sngerare
 durere
 stagnant
 lent
 periodicitate
 da

ani _______
 brusc
 neprovocat
 tumefacie
 mobilitate
 rapid
 n pusee (stare de activitate / inactivitate)
 nu

ANTECEDENTE
ANTECEDENTE HEREDO-COLATERALE
Antecedente heredo-colaterale generale:
Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________

Antecedente heredo-colaterale stomatologice:


Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________

ANTECEDENTE PERSONALE
Antecedente personale generale:
Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________

Antecedente personale stomatologice:


Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________

CONDIII DE VIA I MUNC


Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________

FACTORII DE RISC PARODONTAL


Vrsta: _______
Obiceiuri vicioase:
fumat
alcool

 da
 da
nr. igri / zi ______

frecven
 cosumator ocazional
tip
 bere
 vin
Tipul de alimentaie (carbohidrai, etc.):

 nu
 nu
de cnd ______ luni / ______ ani
 frecvent
 trii

 cronic

Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________
Igiena oral deficitar:
periaj dentar
nr. periaje / zi ______
tip periaj __________________
substane antiplac
 folosire zilnic
 rar
Tratamente dentare defectuoase:
 lucrari protetice
 obturaii
Malocluzii:
 da
 nu
Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________
Respiraia oral:
 da
 nu
Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________
Istoric de boala parodontal:
 da
 nu
 da
 nu
Stresul:
Afeciuni sistemice (teren imunocompromis):
 diabet
 afeciuni cardiovasculare
 afeciuni hematologice
 afeciuni virale
 infecia HIV
Stri fiziologice:
 pubertatea
 sarcina
 menopauza
Factori ereditari:
Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________
Etnia: _________________________________________________________________________________

IGIENA
 bun

 medie

 necorespunztoare

 dimineaa i seara

 neregulat

 corect
 bass
 charters

 bass modificat
 rotativ

PERIAJUL DENTAR
Ritmicitate:
 dup fiecare mas
Tehnica periaj:
 incorect

PERIUA DENTAR
Tipul periutei:
Duritate:
Schimbat la:

 manual
 moale
 3 luni

 electric
 medie
 deteriorare

 cosmetic

 medical

 dur

PASTA DE DINI
MIJLOACE SUPLIMENTARE DE IGIENA ORAL
Ape de gur
Fir interdentar
Periue interdentare
Scobitori interdentare
Duuri bucale

cronologia cltirilor ______________________________________


durata cltirii
________________________________________
 da
 nu
 da
 nu
 da
 nu
 da
 nu

INDICI DE IGIEN
Indice de plac:
___________________________________________________________________
Indice de plac PLI (Silness & Loe)
______________________________________________________
Indice de tartru
___________________________________________________________________
Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________

EXAMEN EXOBUCAL
TEGUMENTE / MUCOASE
Aspect
Culoare
Integritate
Sensibilitate
Tumefacii
Adenopatii

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________

EXAMEN CLINIC PARODONTAL


Parodoniu de nveli
Gingia marginal
Culoarea:
 roz-coral
 rou intens
 rou-violaceu
Consistena:
 ferm
 moale
Forma:
_________________________________________________________________________
Textura:
 granitat
 neted
Volum:
_________________________________________________________________________
Poziia: zona de pe arcad unde apar modificri.
Inflamaie:
localizare
 localizat
 generalizat
zona _________________________________________________
form:
 acut
 periodic
 cronic

Gingia ataat
 absent

zona _________________________________________________

 ngust
 lat

zona _________________________________________________
zona _________________________________________________

Frenuri bride
Inserare:
 aproape
 mediu
 la distan

zona _________________________________________________
zona _________________________________________________
zona _________________________________________________

Indicele PSR / sextani (cod 0, 1, 2.4)


Sextant 1 __________________

Sextant 2 __________________

Sextant 3 __________________

Sextant 6 __________________

Sextant 5 __________________

Sextant 4 __________________

Parodoniul de susinere
Pungi parodontale:

 supraosoase

 infraosoase

 mixte

 absent

 la periaj

 la sondaj

 spontan

 migrri

 malpoziii

 mobilitate

Sngerarea
Dinii

PARODONTOGRAMA INIIAL
Indice de sntate a papilei inter-dentare:

Meniuni: _____________________________________________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________

MAXILAR

Indicele gingival sau GI: indicele lui Le i Silness (0, 1, 1,5)


______________________________________________________________________
Indice de sngerare papilar PBI
______________________________________________________________________
Indice de sngerare gingival
______________________________________________________________________

Indice de hipercretere
______________________________________________________________________
Indicele CPITN - Community Periodontal Index (0, 1, 2, 3, 4, 5, 6)
______________________________________________________________________
Indice de mobilitate(0, 1, 2, 3)
______________________________________________________________________

Meniuni: _______________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________
5

MANDIBULAR

Indicele gingival sau GI: indicele lui Le i Silness (0, 1, 1,5)


______________________________________________________________________
Indice de sngerare papilar PBI
______________________________________________________________________
Indice de sngerare gingival
______________________________________________________________________

Indice de hipercretere
______________________________________________________________________
Indicele CPITN - Community Periodontal Index (0, 1, 2, 3, 4, 5, 6)
______________________________________________________________________
Indice de mobilitate(0, 1, 2, 3)
______________________________________________________________________

Meniuni: _______________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________
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DIAGNOSTIC PARODONTAL
Cadranul I
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

Cod

Integritatea parodontal
Anatomo-clinic + forma clinic
Abces parodontal
1.1 Gingivita
necomplicata
1.1.1
modulata
1.1.2
1

endocrin
medicamentos

1.2
1.3
1.3.1
1.3.2
1.3.3
1.3.3.1
1.3.3.2
1.3.3.3
1.3.4
1.3.5
1.3.6
2
2.1
2.2
3
3.1
3.2
3.3
3.4
3.5
3.6
3.8
3.9
4
4.1
4.2
4.3
4.4
5
5.1
5.2
5.3
6
6.1
6.2
6.3
6.4
7
7.1
7.2
7.3
8
8.1
8.2
8.2.1
8.2.2
8.2.3
8.2.4

Gingivita ulcero-necrotic
Parodontita
juvenila
rapid progresiva
a adultului
superficiala
medie
profunda

refractara
din SIDA
ulcero-necrotica
Topografie
Localizat
Generalizat
Etiologie
Microbian
Teren
Stri fiziologice
Patologii sistemice
Medicaie
Traumatic
Iatrogenic
Plurifactorial
Tulburri funcionale
Masticatorio
Fizionomice
Fonetice
Deglutiie
Evoluie
Stabilizat
Lent
Rapid
Complicaii
Locale
La distan
Imediate
Tardive
Prognostic
Favorabil
Rezervat
Nefavorabil
Tratament
Netratat
Tratat
corect
incorect
complet
incomplet

PLAN DE TRATAMENT
TRATAMENTUL ETIOLOGIC

1
2
3

Nr. edine
1 2 3 4 5 6 7 8

Manopere

Cod (A)

Consultatia in cadrul dispensarizarii (include si educatia pentru sanatatea


bucodentara, determinarea indicelui de placa bacteriana si a indicilor de inflamatie
parodontali)
Educatia pentru individualizarea tehnicilor de indepartare a placii bacteriene / sedinta
Periaj dentar profesional / sedinta

Igiena oral:
Periua de dini:
Metoda de periaj:
Periua interdentar:
Firul interdentar:
Cltiri antiseptice:
Cod (E)
1
1.1
1.2
1.3
1.4
1.5
1.6
1.7

Manopere

 soft
 circular
 da
 da
 da

 medium
 Charters
 nu
 nu
 nu

Cadranul I

Cadranul II

hard
 Bass

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

Profilaxia i tratamentul antimicrobian


Detartraj manual supra si
subgingival per dinte
Detartraj mecanic supra si
subgingival per dinte
Detartraj ultrasunete
Surfasaj radicular / dinte

Periaj profesional / dinte


Tratament medicamentos local
Tratamentul abcesului
parodontal

TRATAMENTUL CORECTIV
2
2.1
2.2
2.3
2.4
2.5
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7

Tratamentul chirurgical
Chiuretaj in camp inchis
Chiuretaj parodontal in camp
deschis / sextant
Echilibrare ocluzala prin slefuire
selectiva per sedinta
Tratamentul aftei bucale per
sedinta
Tratamentul gingivo stomatitelor per sedinta
Contenie / imobilizare
Contentie provizorie prin ligaturi
de sarma
Imobilizare cu compozite
Imobilizare cu amalgam
Imobilizare cu compozit i srm
Imobilizare cu compozit i plas
de srm
Imobilizare cu compozit i band
de polifibr
Puni stabilizatoare

ETAPA DE MENINERE / CONTROL (la 3 luni, 6 luni, 1 an)


Cod (A)
1

Manopere

Nr. edine
1 2 3 4 5 6 7 8

Consultatia in cadrul dispensarizarii (include si educatia pentru sanatatea


bucodentara, determinarea indicelui de placa bacteriana si a indicilor de inflamatie
parodontali)

MAXILAR

Indicele gingival sau GI: indicele lui Le i Silness (0, 1, 1,5)


______________________________________________________________________
Indice de sngerare papilar PBI
______________________________________________________________________
Indice de sngerare gingival
______________________________________________________________________

Indice de hipercretere
______________________________________________________________________
Indicele CPITN - Community Periodontal Index (0, 1, 2, 3, 4, 5, 6)
______________________________________________________________________
Indice de mobilitate(0, 1, 2, 3)
______________________________________________________________________

Meniuni: _______________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________
9

MANDIBULAR

Indicele gingival sau GI: indicele lui Le i Silness (0, 1, 1,5)


______________________________________________________________________
Indice de sngerare papilar PBI
______________________________________________________________________
Indice de sngerare gingival
______________________________________________________________________

Indice de hipercretere
______________________________________________________________________
Indicele CPITN - Community Periodontal Index (0, 1, 2, 3, 4, 5, 6)
______________________________________________________________________
Indice de mobilitate(0, 1, 2, 3)
______________________________________________________________________

Meniuni: _______________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________
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EVOLUIA PACIENTULUI + DEVIZ


NR. CRT.

DATA

MANOPER (COD)

TARIF

MATERIAL

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

DIAGNOSTIC FINAL
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Caz terminat

Medic,

Pacient,

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