Card design. Recommendations for students on filling out a medical record for a dental patient with defects of hard dental tissues Writing an outpatient record for a dental patient

The current form 043 y was developed, approved and put into circulation on October 4, 1980. The body that approved the document is the USSR Ministry of Health. The form is used by outpatient dental institutions as the main accounting document for recording data about patients and the progress of treatment.

A dental patient card form 043 is issued for all citizens who seek help. The document exists in one copy for each patient. The number of specialists who took part in the treatment of the patient does not matter. All data is compiled into one card.

Card form 043 y is produced in A5 format. This is a notebook that includes a title page and pages with ready-made columns for entering data. The form includes an agreement for the provision of dental services, which must be signed by the patient after reading the text of the agreement. The title page must contain the exact full name of the institution. Each card has its own unique individual number.

The dental patient card form 043 must contain the patient’s passport data. This sheet is filled out at the registration desk. The basis is documents proving the identity of the applicant. The patient enters information about his health into the card.

Information about your health status should include such important parameters as the presence of allergies, blood type and Rh factor, chronic diseases of internal organs, existing head injuries, medications currently taken, etc. It is extremely important to provide as much information as possible. This will help the specialist choose the safest and most effective treatment.

Diagnosis of diseases of the teeth and oral cavity may include both visual examination and x-ray examinations. The use of an X-ray machine involves exposing the patient to radiation. The received radiation dose must also be recorded in the card.

Pages with examination results, data on diagnosis and treatment progress are filled out by specialists performing the relevant procedures. The patient must document his or her agreement to the examination and treatment plan.

An important feature of filling out the form is the ability to write down the names of drugs in Latin. The rest of the information is entered only in Russian. Text entered by hand must be legible. Corrections are confirmed by signature.

Medical card 043 y is the property of the clinic.

According to the instructions, dental card form 043 is not issued in person. This legal document can be used in the event of litigation or claims from the patient. In an outpatient dental facility, the card is stored for 5 years. After this period, the form is transferred to the organization’s archives. The archival storage period is 75 years.

Unlike most established forms of medical forms, Form 043 is advisory. The form can be supplemented and adjusted to suit the needs of a specific medical institution. In the City Blank printing house it is possible to order such adjustments to the form, taking into account all the customer’s requirements.

The document can be shortened, supplemented, and columns adjusted. To preserve the protective functions of the document, it is recommended not to exclude important points of the form, for example, an agreement on consent to the provision of services, data on the primary diagnosis. The completeness of the data confirms the quality of the services provided.

You can buy a dental patient’s medical record either in a single copy or in a batch of the required volume. For institutions in Moscow and the Moscow region, delivery by courier is possible. Non-standard forms are printed after final approval.

Medical record of a dental patient
No. April 27, 2002
Last name, first name, patronymic: Ivanov Ivan Ivanovich Gender male. Address Moscow. Age: 10/01/1966
Contact numbers: 452-17-73 Profession: teacher. Diagnosis: 1 1 Average caries Complaints about the presence of a cavity, food ingestion, pain from temperature stimuli (indicate a change in tooth color, an aesthetic defect). Previous and concomitant diseases: considers himself healthy, or: concomitant somatic cytology (hypertension, allergic reactions, head injuries, heart disease, lung disease, hepatitis, venereal disease)

Examination of the oral cavity. Condition of teeth. Legend: none -
O, root - ?, caries - C, pulpitis - R, periodontitis-filled - P, periodontosis - A, mobility - I, II, III (degree), crown - K, claim. tooth - I



8	7	6	5	4	3	2	1	1	2	3	4	5	6	7	8

mild diseases, etc.: acute conditions at the time of treatment!
Development of the present disease: went to the clinic, indicate: for advice on sanitation of the oral cavity, in connection with the appearance of a cavity, in connection with the emerging aesthetic defect, painful sensations.
Objective research data, external examination
The configuration of the line is not changed, or is changed due to swelling of the soft tissues in the area (specify). The skin over the swelling is not changed in color (changed). folds easily 1does not fold). Lymph nodes are not palpable; palpable). 1-3 increased to 0.5 cm in diameter, mobile, soft elastic consistency (dense and immobile)
Dental deposits, their location and quantity:
Bite (specify what kind) orthognathic
Condition of the mucous membrane of the oral cavity, gums, alveolar processes and palate: Pale pink, moderately moisturized, or: hyperemic (with a bluish tint) and swollen in the area of all teeth or a group of teeth. bleeds when touched.

X-ray laboratory data Date (day, month, year).
On visiogram 11 there is a defect in the coronal part 11, in the area of the medial angle. The ratio of the carious cavity to the tooth cavity, the condition of the periodontal gap; osteoporosis or osteoporosis of the bone tissue surrounding the causative tooth, the presence of areas of bone tissue close in density to the tooth tissue, the presence of cavities or other formations in the part being examined.
Dear patient!
General diseases can affect the treatment process at the dentist, so we ask you to carefully fill out this form.
We guarantee that the information you provide in the questionnaire will be used only to select treatment based on your health and will not be available to third parties.
“*- QUESTIONNAIRE (to be filled out by the patient)
I report the following about my health status:
Last visit to the dentist
(indicate month and year.)
Not really

Allergies (drug, food, others)

Symptoms
What stops an attack?

Blood type_Rh factor
Do you suffer from diseases:

heart (angina, palpitations, shortness of breath)
kidney
liver
gastrointestinal tract
lungs (bronchial asthma)

Do you suffer from:

high blood pressure
low blood pressure

Do you have seizures, fainting, or dizziness?
Prolonged bleeding after cuts
Diabetes
Pregnancy
Medications taken (specify)
Have you ever had a head injury?
Past hepatitis
AIDS, sexually transmitted diseases
Recurrent oral ulcers, herpes
Bruxism (night grinding of teeth)
Diseases of the maxillary sinuses
Do you use drugs?
Do you smoke

19.
I sincerely answered all points of the questionnaire, I would like to additionally inform you about the state of my health as follows:
I know that only in the case of mandatory preventive examinations (once every 6 months) can the results of treatment and prosthetics be calculated for a certain period of time.
I know that if I take medications before visiting the dentist, I must inform the doctor about this.
" " 200_ year Patient's signature
AGREEMENT FOR PROVISION OF DENTAL SERVICES No.
Option A. Survey agreement
" " 200_ g.
We, the undersigned, are referred to as
hereinafter CONTRACTOR, represented by the General Director
, acting on the basis of the Charter,
license No. from "_" 200_g. for the provision of medical services
Decrees of the Government of the Russian Federation of January 13, 1996. No. 27 with one
sides, and

The contractor undertakes to instruct a doctor.

(Full name of doctor)

Carry out an interview and examination of the CUSTOMER at the time agreed upon with the CUSTOMER to establish a preliminary diagnosis, the scope of necessary treatment and comprehensively inform the CUSTOMER about the results of the examination, reflecting the preliminary diagnosis and treatment plan in the CUSTOMER’s outpatient record. In the outpatient department
On the chart, the CUSTOMER makes a written note about familiarization with the preliminary diagnosis, treatment plan and possible complications.
The CUSTOMER undertakes to pay the cost of the actions provided for in clause 1.1 of this agreement at the prices of the price list, which the CUSTOMER has previously read.
The CUSTOMER agrees that during the preliminary review it may be necessary to carry out additional (special)

cialized) research methods, by carrying out radiographic and other necessary diagnostic measures, which are carried out by the CONTRACTOR for a fee. If the CONTRACTOR does not have the appropriate technical capabilities, the CONTRACTOR reserves the right to refer the CUSTOMER to another specialized medical organization.

Option B. Treatment agreement
" " 200 g.
We, the undersigned,
hereinafter referred to as the CONTRACTOR, represented by the General Director, the current
on the basis of the Charter, license No. dated " " 200 per oka
knowledge of medical services and Decree of the Government of the Russian Federation of January 13, 1996 No. 27 on the one hand, and,
hereinafter referred to as the CUSTOMER, on the other hand, have entered into this agreement as follows:

The CONTRACTOR undertakes:

In accordance with the preliminary diagnosis and treatment plan included in the CUSTOMER’s outpatient card (clause 1.1 of agreement No. /Aot 200_)
Doctor

(Full name of doctor)
who is obliged to provide high-quality and most painless treatment methods in accordance with medical indications, using painkillers if necessary.

In the event of an unexpected absence of the attending physician on the day appointed for treatment, the CONTRACTOR has the right to appoint another doctor to carry out the treatment.

The CUSTOMER undertakes:

follow all instructions of the attending physician and medical personnel.
Appear for treatment at the scheduled time, agreed with the doctor.
Maintain good oral hygiene and attend scheduled medical check-ups.
Pay for medical services according to the price list, which the CUSTOMER has read before concluding this agreement.

The CUSTOMER agrees that special types of treatment will be carried out by relevant specialists of the CONTRACTOR.
The CONTRACTOR is liable in the event of non-fulfillment or poor performance of its obligations in the presence of its fault.
In the event of a disagreement between the CONTRACTOR and the CUSTOMER regarding the quality of services provided, the dispute between the parties is considered by the chief physician (deputy chief physician) of the CONTRACTOR. If disagreements are not resolved, disputes are considered by clinical expert commissions and (or) experts from territorial organizations of the Dental Association (All-Russian) in the prescribed manner.
Other conditions for all types of dental services, except for periodontology, there is a 36-month guarantee, provided that the CUSTOMER regularly comes for a preventive examination with the CONTRACTOR at least once every 6 months.

CONTRACTOR CUSTOMER
(Patient's full name)

SAMPLE CARD MAINTENANCE

Abbreviations are not allowed in the outpatient card;
When a filling is found, it is indicated on what surface of the tooth it is located^;
When a cavity is formed, its Black class is indicated.

Average caries
Complaints: short-term pain from cold, sweet foods, the presence of a cavity. Indicate the tooth formula.
Objectively: on the (name) surface, (tooth formula) there is a carious cavity of medium depth, filled with softened, pigmented dentin. Probing is painful along the enamel-dentin border. Short-term pain from temperature stimuli. Percussion is negative.
Treatment: Under topical anesthesia, drug, concentration, dose and infiltration (conduction) anesthesia, drug, adrenaline concentration and dose, a cavity is formed according to the class (specify), the bottom is light, dense. The cavity was treated with medication (specify with what). On the (name) surface there is a description of the manipulations performed - filling, restoration, etc., with the name of the material and an indication of the color. Grinding, polishing.
Deep caries
Complaints: the presence of a carious cavity, food ingress, short-term pain from temperature stimuli in (specify the tooth formula).
Objectively: on the (name) surface of (specify the tooth formula) there is a deep carious cavity filled with softened dentin. Probing is slightly painful along the bottom of the carious cavity and along the enamel-dentin border. Rapid response to temperature stimuli. Percussion is negative.
Treatment: Under topical anesthesia, drug, concentration, dose and infiltration (conduction) anesthesia name, adrenaline concentration and dose, a cavity is formed and medicinally treated (specify with what) according to (specify) class. The bottom is light
(weakly pigmented), dense. Medical pad (name). Insulating gasket (name). On the (name) surface all the manipulations performed are described - filling, restoration, inlay, etc., with the name of the material and an indication of the color. Grinding, polishing.
The patient is warned about the possibility of pain and the need to denervate the tooth. ,
Patient signature

X-ray analysis

Assessment of the crown part of the tooth (shape, contours, presence of carious cavities, their relationship to the tooth cavity);
Tooth cavity (presence, absence, shape, size, structure, presence of perforations);
Tooth root (number, size, shape, contours; fracture, perforation, degree of formation and resorption);
Root canal (presence, absence, width, obliteration, curvature, in the presence of filling material - degree of filling, foreign bodies);
Condition of the periodontium (expansion of the periodontal fissure, loss of bone tissue); f
Bone tissue of the alveolar processes of the jaws (destruction, osteoporosis, osteosclerosis);
Cortical plate (preserved, destroyed);
Interalveolar septa (character of contours, structure, changes in ridges).

The classification of caries used in Russia is based on topographical criteria, although priority is given to the WHO classification of the Xth revision.
^

I. DEFINITION OF CARIES

This is a pathological process in the hard tissues of the tooth, which manifests itself after teething and is expressed in demineralization and softening of the hard tissues of the tooth, which most often ends in the formation of a cavity.

^ CARIES IN THE STAIN STAGE or carious demineralization

The examination reveals a loss of the natural shine of the enamel in a limited area and a change in color to dull white (progressive demineralization).

INSPECTION:

examination, probing, staining of spots on enamel for the purpose of differential diagnosis with non-carious lesions.

The goal of treatment is to stabilize the carious process.

Cleaning the affected enamel surface with prophylactic paste "Radent";

Treatment of stains localized in areas that are not visible when smiling with the drug "Saforide" (due to possible staining of teeth);

Treatment of spots localized in areas noticeable when smiling with the preparation "Stangard", fluoride varnish - "Komposil";

Treatment of affected areas of enamel with Stangard gel at home for 2 months.

1) disappearance of enamel stains

2) restoration of the shine of the enamel surface in the affected area.
^

II.SUPERFICIAL CARIES

It occurs at the site of a white or pigmented carious spot as a result of destructive changes in tooth enamel. It can be localized both on the smooth surface of the tooth and in the fissure area.

INSPECTION:

inspection, probing, staining with a "Caries Detector".

Cleaning the surface of teeth using Radent paste;

Brown spots with a rough surface are subject to preparation and filling. In this case, filling materials are used: “Citrix”, “Cimex”, “AMSO”, “Lysix”, “Clearfil”.

Dentin protection - materials "Komposil", "Cimex", "Lika", "Clerafil Liner Bond 2V";

When filling with materials "Citrix", or "Clerafil AR-X", "Clerafil ST" - there is no need to apply a gasket and etching.

In case of superficial lesions in the area of fnsur, it is necessary to treat the surface with the preparations "Saforaid", "Composil" and carry out dynamic monitoring during repeated examinations every 3 months.

If the dynamics are positive, seal the fissures with Titmate sealant.

Requirements for treatment results:

Absence of recurrent caries at the “tooth tissue - filling” interface;

Stabilization of the process in the fissure area.
^

III. MEDIUM CARIES

With this form of carious lesion, the integrity of the enamel-dentin junction is compromised, but a fairly thick layer of unchanged dentin remains above the dental pulp. Characterized by the presence of short-term pain from temperature, mechanical and chemical stimuli, which disappear immediately after the removal of the stimulus.

INSPECTION:

questioning, examination, instrumental examination (probing, percussion), electroodontodiagnosis, in unclear cases - x-ray examination for differential diagnosis with chronic periodontitis.

^ CHARACTERISTICS OF TREATMENT MEASURES:

Carrying out pain relief (filtration, conduction, etc.)

Cleaning the surface with Radent paste;

cavity preparation with removal of necrotic and pigmented tissues;

Application of the adhesive system (Clerafil Liner Bond 2V, Panavia F)

When filling with Citrix material, there is no need to apply a gasket or etching;

Application of filling material "Clerafil", "Lysix".

Requirements for treatment results:

Lack of hypersensitivity to temperature, mechanical and chemical stimuli;

IV. DEEP CARIES

Characterized by a significant spread of the process to the dentin of the tooth.

INSPECTION:

questioning, examination, instrumental examination, electroodontodiagnosis, temperature test, differential diagnosis with moderate caries, with chronic forms of complicated caries.

^ CHARACTERISTICS OF TREATMENT MEASURES.

If there are difficulties in diagnosis, apply a diagnostic seal.

Carrying out pain relief

Removal of overhanging edges of enamel and softened dentin

Applying a therapeutic pad "Tsimex", "Lika", "Liner Bond".

Applying a temporary dressing with Cimex material.

Assessment of the quality of preparation with a "Caries Detector";

With a diagnosis of “Deep caries”:

Carrying out pain relief;

Carrying out preparation;

Checking the quality of preparation with a “Caries Detector”;

Application of a medical pad made of materials "Lika", "Cimex", "Liner Bond";

Application of insulating gasket "Tsimex", "Lika";

Dentin protection - with varnishes or pads "Komposil", "Tsimex", "Lika";

Application of the adhesive system (Clerafil Liner Bond 2V, Panavia F), Lika, Cimex, Komposil.

Application of filling material "Tsntrix"

Requirements for treatment results:

No hypersensitivity

No recurrent caries;

restoration of functional, anatomical and aesthetic parameters of the tooth.
^

V. PREVENTIVE SEALING OF TEETH FIGURES

It is carried out to prevent the development of fissure caries.

SURVEY

It is carried out to identify the type of fissures that are subject to preventive sealing. Inspection, staining, instrumental examination.

^ EVENT CHARACTERISTICS

Cleaning the fissure with Radent paste;

Sealing the fissure with Titmate sealant or treatment with Saforaid.

Requirements for sealing results:

Absence of carious lesions of fissures.

^ VI. COMPLICATIONS OF CARIES

VI. I PULPITIS

(Acute, chronic, in the acute stage). Inflammation of the pulp and tooth, mostly with pain.

INSPECTION:

questioning, examination, instrumental examination, electroodontodiagnostics, temperature test, x-ray examination.

^ CHARACTERISTICS OF TREATMENT MEASURES:

Anesthesia

Removal of the pulp under anesthesia or with the preliminary application of devitalizing agents: arsenic paste;

Mechanical and medicinal treatment of root canals using sodium hypochlorite solution "Neoklzner Sikain";

Filling root canals with Vitapex paste and other types of pastes with gutta-percha;

Application of an insulating pad;

In case of significant curvature of the root canals and in other cases when complete removal of the pulp is impossible, the mummifying drug "Neo Triozinc Paste" should be used.

Requirements for treatment results:

Stopping pain;

Absence of destructive processes in the periodontium in the long term.

VI. II^ PERIODONTITIS, APICAL

(Acute, chronic, in the acute stage). Pulp necrosis with destructive changes in the periodontium.

INSPECTION:

questioning, examination, instrumental examination, x-ray examination.

^ CHARACTERISTICS OF TREATMENT MEASURES FOR CONSERVATIVE TREATMENT OF APICAL PERIODONTITIS:

In the acute period - pain relief

Preparation and opening of the tooth cavity;

Removing the contents of the root canal and exudate with copious rinsing with antiseptic solutions;

Mechanical treatment of the root canal using EDTA;

When treating acute and aggravated forms of periodontitis, the tooth is left open for 3-7 days. According to indications, antibiotics are prescribed in combination with antihistamines; mandatory rinsing;

After stopping the acute process and in the presence of a chronic process in the presence of zones of periapical destruction of bone tissue, temporary obturation of the root canals should be used using osteotropic drugs: “Iodo-glycol paste”.

Before the final obturation, medicinal treatment and drying of the root canal are carried out;

Obturation of the root canal using the Vitapex material, if necessary, in combination with gutta-percha;

Application of an insulating gasket "Cimex";

Application of a permanent filling.

Requirements for treatment results:

Stopping pain;

In the long term - restoration of bone tissue in the destruction zone.

^ Superficial caries

No complaints. He came for the purpose of sanitation of the oral cavity. Objectively: a carious cavity on the medial surface of the 16th tooth is located in the center of a large chalky spot, within the enamel.

Complaints of short-term pain from chemical irritants (sweet, sour, salty).

Objectively: a carious cavity on the chewing surface within the enamel, probing is painless; EDI=3 µA.

Diagnosis: superficial caries of the 16th tooth.

Treatment: preparation of the carious cavity, medicinal treatment with 3% sodium hypochloride solution, filling from Valux plus CPM.

Average caries

No complaints. He came for the purpose of sanitation of the oral cavity. Objectively: a carious cavity on the chewing surface of the 27th tooth within its own dentin, filled with pigmented dentin, probing is painful along the enamel-dentin border.

Treatment: preparation of the carious cavity, medicinal treatment with 3% sodium hypochloride solution, filling from Valux plus CPM.

Complaints of short-term pain when eating sweet foods.

Objectively: a carious cavity on the chewing surface of the 27th tooth, within its own dentin, probing is painless, there is no reaction to temperature stimuli; EDI=5 µA.

Diagnosis: average caries of the 27th tooth.

Treatment: preparation of the carious cavity, medicinal treatment with 3% sodium hypochloride solution, filling from Valux plus CPM.

Complaints of short-term pain when eating.

Objectively: a carious cavity on the chewing surface of the 27th tooth, within its own dentin, probing is painless, there is no reaction to temperature stimuli. Preparation syndrome positive (preparation is painful)

Diagnosis: average caries of the 27th tooth.

Treatment: preparation of the carious cavity, medicinal treatment with 3% sodium hypochloride solution, filling from Valux plus CPM.
^

Deep caries

Complaints of fleeting pain in the 46th tooth while eating. Objectively: on the chewing surface of the 46th tooth there is a deep carious cavity within the peripulpal dentin, probing is painless; EDI=8 µA.

Complaints of short-term pain from temperature stimuli.

Objectively: the chewing surface of the 46th tooth is deep

carious cavity within the peripulpal dentin, probing is painful along the entire bottom, a sharp reaction to a cold stimulus, the pain goes away immediately after the stimulus is removed.

Diagnosis: deep caries of the 46th tooth.

Treatment: preparation of a carious cavity, medicinal treatment with 3% sodium hypochloride solution, calcium hydroxide (Dycal) on the bottom, gasket (Duract), filling made of CPM Valux plus.

Complaints of pain in the 46th tooth when eating.

Objectively: on the chewing surface of the 46th tooth there is a deep carious cavity within the omolopulpal dentin, probing is painful along the entire bottom, the dentin is dense, there is no communication with the pulp chamber.

Diagnosis: deep caries of the 46th tooth.

Treatment: preparation of a carious cavity, medicinal treatment with 3% sodium hypochloride solution, calcium hydroxide (Dycal) on the bottom, gasket (Duract), filling made from KPM Valux plus.

PULPITES

^ Acute focal pulpitis

Complaints of sharp pain in the 18th tooth for 2 days. Objectively: in the 18th tooth there is a deep carious cavity within the ojuulopulpar dentin, filled with softened dentin, probing is painful in the area of the projection of the medial pulp horn, the tooth cavity is not opened. Percussion is painless.

Diagnosis: acute focal pulpitis of the 18th tooth.

Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml preparation of the carious cavity, medicinal treatment with 3% sodium hypochloride solution on the bottom, calcium hydroxide (Dycal), gasket (Dyract), filling from KPM Valux plus.

Complaints of pain when eating for 2 days. Objectively: in the 18th tooth there is a deep carious cavity within the peripulpal dentin, filled with softened dentin, probing is painful in the area of the projection of the medial pulp horn, the tooth cavity is not opened. Percussion is painless; EDI==12 µA. Diagnosis: acute focal pulpitis of the 18th tooth. Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml, preparation of the carious cavity was carried out, medicinal treatment with 3% sodium hypochloride solution, calcium hydroxide (Dycal) on the bottom, gasket (Dyract), filling from KPM Valux plus.

Acute diffuse pulpitis

Complaints of paroxysmal night pain in the left upper jaw.

Objectively: on the chewing surface of the 26th tooth there is a deep carious cavity within the peripulpal dentin, the pulp chamber is not opened, probing is painful, percussion is sharply painful.

Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml carried out preparation of a carious cavity, opening of the tooth cavity, deep amputation of the coronal and extirpation of the root pulp, expansion of the root canals and medicinal treatment with 3% sodium hypochloride solution, filling of the root canals AN-26. Temporary filling. Referral for control radiography.

On the radiograph dated May 16, 2005, the root canals of the 26th tooth are filled to the physiological apexes. Filling made from KPM Herculite XRV.

Complaints of sharp paroxysmal, long-lasting pain from a hot temperature stimulus. Cold pain The tooth had not previously hurt.

Objectively: on the chewing surface of the 26th tooth there is a deep carious cavity within the peripulpal dentin, the pulp chamber is not opened, probing is painful, percussion is sharply painful; EDI=25 µA.

Diagnosis: acute diffuse pulpitis of the 26th tooth.

Treatment: under infective anesthesia Sol. Ultracaini 2%-1.7 ml prepared the carious cavity and opened the tooth cavity. deep coronal amputation and extirpation of root pulp, expansion of root canals and drug treatment with 3% hypochloride solution pain. The pain intensifies in the evening and at night. The tooth had not previously been sick. Sodium, root canal filling AN-26. Temporary filling. Referral for control radiography.

On the X-ray dated May 17, 2005. The root canals of the 26th tooth are sealed to the physiological apexes. Filling made from KPM Herculite XRV.

Complaints of spontaneous, paroxysmal, long-lasting, radiating pain.

Objectively: there is an acrylic oxide filling on the chewing surface of the 26th tooth, percussion is sharply painful; EDI 20 µA.

Diagnosis: acute diffuse pulpitis of the 26th tooth.

Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml: removal of the filling, opening of the tooth cavity, deep amputation of the coronal and extirpation of the root pulp, expansion of the root canals and medicinal treatment with 3% sodium hypochloride solution, filling of the root canals AN-26. Temporary filling. Referral for control radiography. On the radiograph dated May 18, 2005. The root canals of the 26th tooth are sealed to the physiological apexes. Filling made from KPM Herculite XRV.

Chronic fibrous pulpitis

No complaints.

Objectively: on the chewing surface of the 26th tooth there is a deep carious cavity communicating with the tooth cavity, probing is sharply painful at this point, the pulp is bleeding,

Treatment: under tuberal anesthesia Sol. Lidocaini 2%-4.0%, preparation of the carious cavity, deep amputation of the coronal and extirpation of the root pulp, mechanical expansion of the root canals, medicinal treatment with 3% sodium hypochloride solution, filling of the root canals AN-26 were carried out. Temporary filling. Referral for control radiography.

On the x-ray dated May 19, 2005, the root canals of the 26th tooth are sealed to the physiological apexes. Filling made from KPM Herculite XRV.

Complaints of aching pain and discomfort in the tooth when approaching from a cold to a warm room.

Objectively: on the chewing surface of the 26th tooth there is a deep carious cavity communicating with the tooth cavity, probing is sharply painful at this point, the pulp is bleeding; EDI = 40 µA.

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

Treatment: under tuberal anesthesia Sol. Lidocaini 2%-4.0, preparation of the carious cavity, deep amputation of the coronal pulp and extirpation of the root pulp, mechanical expansion of the root canals, medicinal treatment with 3% sodium hypochloride solution, filling of the root canals AN-26 were carried out. Temporary filling. Referral for control radiography.

On the x-ray dated May 20, 2005, the root canals of the 26th tooth are filled to the physiological apexes. Filling made from KPM Valux plus.

Complaints of pain when eating food at contrasting temperatures.

Objectively: the crown of the 26th tooth is significantly destroyed, there is a deep carious cavity on the chewing surface, communicating with the cavity of the tooth, probing is sharply painful at this point, the pulp is bleeding.

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

On the radiograph dated May 21, 2005, the root canals of the 26th tooth are filled to the physiological apexes. Filling made from KPM Herculite XRV.

Complaints of aching pain while eating food of contrasting temperatures and transitioning from a cold room to a warm one.

Objectively: there is a filling on the chewing surface of the 26th tooth, percussion is painless, EDP = 35 µA.

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

PRACTICAL GUIDE FOR DOCTORS(advanced medical technologies)Printed by decision of the Methodological Council

GOU DPO KSMA Roszdrav

Approved

Ministry of Health

Republic of Tatarstan

Minister A.Z. Farrakhov

Reviewers:

Doctor of Medical Sciences, Professor R.Z. Urazova

Doctor of Medical Sciences, Associate Professor T.I. Sadykova

Kazan: 2008

Introduction

"Medical record of a dental patient" refers to medical documentation, form No. 043/u, which is indicated on the front page of the form. Before the patient’s medical history begins, the official name of the medical institution is indicated on the front side of the card, the registration number is affixed, and the date of its compilation is noted.

Dental diseases are one of the most common pathologies, which forces you to seek help from a dentist.

The goals of examining a patient with pathology of hard dental tissues are to assess the general condition of the body, clinical characteristics of the teeth, identify general and local etiological and pathogenetic factors, determine the form and nature of the course and localization of the pathological process.

The most complete information allows you to correctly diagnose the disease and effectively plan complex treatment and prevention. The doctor obtains the necessary set of differential diagnostic indicators by carefully collecting anamnesis, a detailed clinical examination, and using additional examination methods and laboratory research methods.

When filling out a dental patient’s medical record, it is necessary to take into account the “Medico-economic standards for therapeutic dentistry”, developed in the Republican Dental Clinic of the Ministry of Health of the Republic of Tatarstan for the region in 1998 on the basis of clinical and statistical groups in dentistry approved by the Ministry of Health of the Russian Federation in 1997. There is an order of the Ministry of Health of the Republic of Tatarstan No. 360 dated April 24, 2001. paragraph 2, which approves “methodological recommendations for filling out a dental patient’s medical record.”

Currently, there are already standards for "Dental caries", approved by the Ministry of Health and Social Development of the Russian Federation on October 17, 2006.

Case history diagram

General information (Profile details).

1. Last name, first name, patronymic of the patient

2. Age, year of birth

4. Place of work

5. Position held

6. Home address

7. Date of visit to the clinic

8. Informed voluntary agreement to the proposed treatment plan (this is not in the medical record and, most likely, should be included as an appendix).

I.Patient's complaints.

1. Main complaints.

These are complaints that bother the patient in the first place and are most characteristic of this disease. As a rule, the patient complains of pain. It is necessary to find out the following criteria for a pain symptom:

a) localization of pain;

b) pain is spontaneous or causal;

c) the reason for the appearance or intensification of pain;

d) intensity and nature of pain (aching, tearing, throbbing);

e) duration of pain (periodic, paroxysmal, constant)

f) presence or absence of night pain;

g) presence or absence of irradiation of pain, area of irradiation;

h) duration of painful attacks and light intervals;

i) factors that relieve pain;

j) the presence or absence of pain when biting a tooth (if

if there is no lei, then indicate that the diseased tooth was discovered during the examination);

k) were there any exacerbations, what were their causes.

2. Additional complaints

These are data that are not related to the main complaints and are usually a consequence of some physical disease. Additional complaints are identified actively, according to a scheme, in a certain sequence:

2.1 Digestive organs.

1. Feeling of dry mouth.

2. The presence of increased salivation.

3. Thirst: how much fluid does he drink per day?

4. Taste in the mouth (sour, bitter, metallic, sweetish, etc.)

5. Chewing, swallowing and origin of food: free, painful, difficult. What food does not pass through (solid, liquid).

6. Bleeding from the oral cavity: spontaneous, when brushing teeth, when eating hard foods, absent.

7. Having bad breath.

3. Complaints that determine the general condition

General weakness, malaise, unusual fatigue, increased body temperature, decreased performance, weight loss (how much and over what period).

II.History of the present disease.

The occurrence, course and development of the present disease from the moment of its first manifestations to the present.

1. When, where and under what circumstances the disease occurred.

2. What does the patient associate his illness with?

3. Onset of the disease - acute or gradual.

4. First symptoms.

5. The initial symptoms of the disease, their dynamics, the appearance of new symptoms, their further development until the moment of contacting the therapeutic dentistry clinic and the beginning of the present examination of the patient are described in detail, in chronological order. In the chronic course of the disease, it is necessary to find out the frequency of exacerbations, the reasons that cause them, the relationship between the time of year or other factors. The presence or absence of progression of the disease as exacerbations occur.

6. Diagnostic and therapeutic measures based on medical history (old radiographs, records in the outpatient card, etc.). What diagnosis was made? Duration and effectiveness of previous treatment.

7. Characteristics of the period preceding the present application to the therapeutic dentistry clinic. Have you been registered with a dispensary, or received preventive treatment (what and when). Last exacerbation (for chronic diseases), time of onset, symptoms, previous treatment.

III.History of the patient's life.

The purpose of this stage is to establish the connection of the disease with external factors, living conditions, and previous diseases.

1. Place of birth.

2. Material and living conditions in childhood (where, how and in what conditions he grew up and developed, the nature of feeding, etc.).

3. Work history: when you started working, the nature and conditions of work, occupational hazards in the past and present. Subsequent changes in work and place of residence. Detailed description of the profession. Work indoors or outdoors. Characteristics of the working area (temperature, its fluctuations, drafts, dampness, lighting, dust, contact with harmful substances). Working hours (day work, shift work, length of working day). Psychological atmosphere at work and at home, use of weekends and vacations.

4. Current living conditions.

5. The nature of the diet (regular or not, how many times a day, at home or in the dining room), the nature of the food taken (sufficiency, addiction to certain foods).

6. Habitual intoxications: smoking (from what age, number of cigarettes per day, what one smokes); drinking alcohol; other bad habits

7. Previous diseases, injuries of the maxillofacial area and a detailed description of previous and concomitant diseases from early childhood before admission to the therapeutic dentistry clinic, indicating the year of the disease, the duration and severity of the complications that arose, as well as the effectiveness of the treatment. A separate question about past sexually transmitted diseases, tuberculosis, hepatitis.

8. Illnesses of immediate relatives. State of health or cause of death (indicating life expectancy) of parents and other close relatives. Pay special attention to tuberculosis, malignant neoplasms, diseases of the cardiovascular system, syphilis, alcoholism, mental illness, and metabolic disorders. Create a genetic picture.

9. Tolerance of drugs. Allergic reactions.

Information obtained from collecting anamnesis is often crucial for clarifying the diagnosis. It should be emphasized that the anamnesis must be active, that is, the doctor must ask the patient purposefully, and not listen to him passively.

Objective examination data

An objective examination consists of inspection, palpation, probing and percussion.

I. Inspection.

When examining, pay attention to:

1. General condition (good, satisfactory, moderate, severe, very severe).

2. Type of constitution (normosthenic, asthenic, hypersthenic).

3. Facial expression (calm, excited, indifferent, mask-like, suffering).

4. Patient’s behavior (sociable, calm, irritable, negative).

5. Presence or absence of asymmetry.

6. Condition of the red border of the lips and corners of the mouth.

7. Degree of mouth opening.

8. The patient’s speech (intelligible, slurred)

9. Skin and visible mucous membranes:

color (pale pink, dark, red, pale, jaundiced, cyanotic, earthy, brown, dark brown, bronze (indicate places of color on visible skin, etc.);
skin depigmentation (leukoderma), albinism;
swelling (consistency, severity and distribution);
turgor (elasticity) of the skin (normal, reduced);
degree of humidity (normal, high, dry). The degree of moisture in the oral mucosa;
rashes, rashes (erythema, spot, roseola, papule, pustule, blister, scales, crust, cracks, erosions, ulcers, spider veins (indicating their location);
scars (their nature and mobility)
external tumors (atheroma, angioma) - location, consistency, size.

10. Lymph nodes:

localization and number of palpable nodes: occipital, parotid, submandibular, chin, cervical (anterior, posterior);
pain on palpation;
shape (oval, irregular round);
surface (smooth, bumpy);
consistency (hard, soft, elastic, homogeneous, heterogeneous);
welded to the skin, surrounding fiber and their mobility among themselves;
size (in mm);
condition of the skin above them (color, temperature, etc.).

II. Plan and sequence of oral examination.

A healthy person has a symmetrical face. The lips are quite mobile, the upper one is 2-3 mm short of the cutting edges of the upper front teeth. Opening the mouth and moving the jaws are free. Lymph nodes are not enlarged. The actual mucous membrane of the mouth is pale pink or pink in color, does not bleed, fits tightly to the teeth, and is painless.

After a general examination of the external parts of the maxillofacial area, the vestibule of the mouth is examined, then the condition of the dentition.

The examination usually begins with the right half of the upper jaw, then examines its left side, the lower jaw on the left; complete the examination on the right side in the retromolar area of the lower jaw.

When examining the vestibule of the mouth, pay attention to its depth. To determine the depth, measure the distance from the edge of the gum to its bottom with a graduated instrument. The vestibule is considered shallow if its depth is no more than 5 mm, medium - 8-10 mm, deep - more than 10 mm.

The frenulum of the upper and lower lips is attached at a normal level. During the examination of the frenulum of the lips and tongue, attention is paid to their anomalies and the height of their attachment.

When assessing the dentition, attention is paid to the type of bite: orthognathic, prognathic, progynic, micrognothia, straight. Separately, the uniformity of teeth closure and the presence of dentoalveolar anomalies, diastemas and three are noted.

The teeth fit tightly to each other and, thanks to contact points, form a single gnathodynamic system. When examining teeth, the presence of plaque is noted, indicating its color, shade and location of stains, relief and defects of enamel, the presence of foci of demineralization, carious cavities and fillings.

III. The most common clinical dental designation systems.

1. Standard square-digital Zygmandy-Palmer system. It provides for the division of the dentofacial system (dentition) into 4 quadrants along the sagittal and occlusal planes. When recorded in a chart, each tooth is indicated graphically, accompanied by an angle corresponding to the location of the tooth in the formula.

This formula is not used. However, the examination of the teeth/dentition is carried out in exactly this sequence: from the right upper jaw to the right lower jaw.

3. When recording on a map, each tooth is indicated by letters and numbers in the following order: first the jaw is indicated, then its side, the tooth number according to its location in the formula.

5. Designations of parts of the oral cavity. For this purpose, codes are used according to accepted WHO standards:

01 - upper jaw

02 - lower jaw

03 - 08 - sextants in the oral cavity in the following order:

sextant 03 - upper right rear teeth

sextant 04 - upper canines and incisors

sextant 05 - upper left rear teeth

sextant 06 - lower left rear teeth

sextant 07 – lower canines and incisors

sextant 08 - lower right rear teeth.

V. Designations of various types of dental lesions.

These designations are entered into the map above or below the corresponding tooth:

C - caries

P - pulpitis

Pt - periodontitis

R - root

F - fluorosis

G - hypoplasia

Cl - wedge-shaped defect

O - missing tooth

K - artificial crown

I - artificial tooth

VI. Probing.

This procedure is carried out using a dental probe. This allows you to make a judgment about the nature of the enamel and identify defects on it. The probe determines the density of the bottom and walls of the cavity in the hard tissues of the teeth, as well as their pain sensitivity. Probing makes it possible to judge the depth of the carious cavity and the condition of its edges.

VII. Percussion.

The method allows you to determine whether there is an inflammatory process in the periapical tissues, as well as complications after filling the proximal surface of the tooth.

VIII. Palpation.

The method is used to detect swelling, the presence of infiltration on the alveolar process or along the transitional fold.

Additional research methods

To make an accurate diagnosis and carry out differential diagnosis of dental diseases, it is necessary to carry out additional examination methods.

I. Assessment of the hygienic state of the oral cavity.

Determining the level of oral hygiene plays an important role in diagnosing and predicting the effectiveness of treatment and preventive measures in dentistry. To assess the hygienic state of the oral cavity, it is recommended to calculate the following hygienic indices (IGPR).

1. The Fedorov-Volodkina hygienic index (written on the card: GI FV) is expressed in two numbers that determine quantitative and qualitative characteristics. This index is determined by the intensity of the color of the labial surface of the six lower frontal teeth (with a solution of methylene blue or Pisarev-Schiller solution).

1.1. Quantitative assessment is carried out using a five-point system:

staining the entire surface of the tooth - 5 points,

3/4 surface - 4 points,

1/2 surface - 3 points,

1/4 surface - 2 points,

absence of staining - 1 point.

The hygienic condition is considered good with a quantitative index value of 1.0 points, with a value of 1.1-2.0, satisfactory, and with a value of 2.1-5.0, unsatisfactory.

1.2. Qualitative assessment:

no staining - 1 point,

weak staining - 2 points,

intense coloring - 3 points.

The hygienic condition is considered good with an index value of 1 point, with a value of 2, satisfactory, and with a value of 3, unsatisfactory.

2. Green & Vermillion Hygiene Index (written on the card: IG GV). Using the authors' method, a simplified hygiene index (OHI-S) is determined, which includes the plaque index and tartar index.

2.1. The dental plaque index is determined and calculated by the intensity of coloring of the surface of the following teeth: buccal - 16 and 26, labial -11 and 31, lingual -36 and 46. Quantitative assessment of the index is carried out using a three-point system:

0—no staining;

1 point - dental plaque covers no more than 1/3 of the tooth surface;

2 points - dental plaque covers more than 1/3, but not more than 2/3 of the tooth surface;

3 points - dental plaque covers more than 2/3 of the tooth surface.

2.2. The tartar index is determined and calculated by the amount of supragingival and subgingival hard deposits on the same group of teeth: 16 and 26, 11 and 31, 36 and 46.

1 point - supragingival calculus is detected on one surface of the examined tooth and covers up to 1/3 of the height of the crown;

2 points - supragingival calculus covers the tooth on all sides from 1/3 to 2/3 of the height, as well as when particles of subgingival calculus are detected;

3 points - if a significant amount of subgingival tissue is detected

stone and in the presence of supragingival stone covering the tooth crown more than 2/3 of the height.

The Green-Vermillion Combined Index is calculated as the sum of the plaque and tartar indices. Each indicator is calculated using the formula:

By Wed. = K and / n

Kcf - general indicator of dental cleanliness

K and - indicator of the degree of coloration of one tooth

n is the number of teeth being examined

The hygienic condition is considered good with an index value of 0.0, with a value of 0.1-1.2, satisfactory, and with a value of 1.3-3.0, unsatisfactory.

To assess this index, the vestibular surfaces of teeth 16, 11, 26, 31 and the lingual surfaces of teeth 36 and 46 are stained. The examined tooth surface is conventionally divided into 5 sections: central, medial, distal, mid-occlusal, mid-cervical. Each section is assessed in points:

0 points - no staining

1 point - coloring of any intensity

The Hygiene Performance Index is calculated using the formula:

The hygienic condition with an index value of 0 is assessed as excellent hygiene, with an index value of 0.1-0.6 as good, with an index value of 0.7-1.6 as satisfactory, with an index value of more than 1.7 it is considered unsatisfactory .

Determination of the rate of formation is carried out by staining the the following surfaces of the teeth (tooth) with Lugol's solution. First, controlled cleaning of the surfaces of the teeth being examined is carried out. Subsequently, the teeth are examined for 4 days and then the surfaces of the same teeth are re-stained.

The degree of coverage of these surfaces with soft plaque is assessed using a five-point system. The difference in staining rates with Lugol's solution on the surfaces of the teeth under study between days 4 and 1 reflects the rate of its formation.

This difference, expressed less than 0.6 points, indicates the resistance of teeth to caries, and a difference of more than 0.6 points indicates the susceptibility of teeth to caries.

II. Vital staining of hard dental tissues.

The technique is based on increasing the permeability, in particular of large molecular compounds. Designed to identify those affected by caries in the early stages of its development. Upon contact with solutions of dyes in areas of demineralized hard tissues, the dye is sorbed, while unchanged tissues are not stained. A 2% aqueous solution of methylene blue is usually used as a dye.

To prepare a solution of methylene blue, add 2 g of dye to a 100 ml volumetric flask and add distilled water to the mark.

The surface of the teeth to be examined is thoroughly cleaned of soft dental deposits with a swab moistened with a 3% solution of hydrogen peroxide. The teeth are isolated from saliva, dried, and cotton swabs soaked in a 2% solution of methylene blue are applied to the prepared enamel surface. After 3 minutes, the dye is removed from the surface of the tooth using cotton swabs or rinsing.

According to E.V. Borovsky and P.A. Leus (1972) distinguishes between light, medium and high degrees of coloration of carious spots; this corresponds to a similar degree of enamel demineralization activity. Using a gradation ten-field halftone scale of various shades of blue, the color intensity of carious spots: the least colored stripe is taken as 10%, and the most saturated - as 100% (Aksamit L.A., 1974).

In order to determine the effectiveness of treatment of initial caries, re-staining is carried out at any time intervals.

III. Determination of the functional state of enamel.

The functional state of enamel can be judged by the composition of the hard tissues of teeth, their hardness, resistance to acids and other indicators. In clinical settings, methods for assessing the resistance of dental hard tissues to acids are becoming widespread.

1. TER test.

The most acceptable method is V.R. Okushko (1990). A drop of 1 normal hydrochloric acid with a diameter of 2 mm is applied to the surface of the central upper incisor, washed with distilled water and dried. After 5 seconds, the acid is washed off with distilled water and the tooth surface is dried. The depth of the enamel etching microdefect is assessed by the intensity of its staining with a 1% solution of methylene blue.

The etched area appears blue. The degree of coloring reflects the depth of damage to the enamel and is assessed using a blue standard printing scale. The more intensely the etched area is colored (from 40% and above), the lower the acid resistance of the enamel.

2. KOSRE-test (Clinical assessment of the rate of remineralization of ema-

This test is designed to determine the resistance of teeth to caries (Ovrutsky G.D., Leontyev V.K., Redinova T.L. et al., 1989). Based on an assessment of both the condition of tooth enamel and the remineralizing properties of saliva.

The enamel surface of the tooth being examined is thoroughly cleaned of plaque with a dental spatula and a 3% hydrogen peroxide solution, and dried with compressed air. Then a drop of hydrochloric acid buffer pH 0.3-0.6 is applied to it, always in a constant volume. After 1 minute, the demineralizing solution is removed with a cotton swab. A cotton ball soaked in a 2% solution of methylene blue is also applied to the etched area of tooth enamel for 1 minute. The compliance of enamel to the action of acid is assessed by the intensity of staining of the etched area of tooth enamel. After 1 day, the etched area of tooth enamel is re-stained without repeated exposure to the demineralizing solution. If the etched area of tooth enamel becomes stained, then this procedure is repeated again after 1 day. The loss of the etched area's ability to stain is regarded as a complete restoration of its mineral composition.

The acid buffer is a demineralizing solution. To prepare it, take 97 ml of 1 normal hydrochloric acid and 50 ml of 1 normal potassium hydrochloride, mix and adjust the volume to 200 ml with distilled water. To give greater viscosity, one part of glycerin is added to one part of this solution. Increased viscosity helps to obtain a drop of it with a constant amount of contact with the tooth and better retention of it on the surface. For better visual control, the demineralizing liquid is tinted with acid fuchsin. In this case, the demineralizing solution becomes red.

The degree of compliance of tooth enamel to the action of acid is taken into account as a percentage, and the remineralizing ability of saliva is calculated in days. People's resistance to caries is characterized by low compliance of tooth enamel to acid action (below 40%) and high remineralizing ability of saliva (from 24 hours to 3 days), and those susceptible to caries are characterized by high compliance of tooth enamel to the action of acid (above or equal to 40%) and low remineralizing ability of saliva (more than 3 days).

IV. Index of intensity of dental caries damage.

The intensity of caries is determined by the average number of carious teeth per person. The intensity is calculated according to the KPU index: K - caries, P - fillings, U - extracted teeth. Depending on the activity of the carious process, WHO distinguishes 5 degrees:

Caries intensity (ICU)
indicators
indicators		from 35 to 44 years
very low
low
moderate
high
very high	6.6 or more	16.3 or more

In childhood, to specify the implementation of preventive measures, it is recommended to adhere to the methodology of T.F. Vinogradova, when the intensity of caries is determined by the degree of caries activity using the indices KP (during the period of temporary dentition), KPU + KP (during the period of mixed dentition) and KPU (during the period of permanent dentition).

The first degree of caries activity (compensated form) is a condition of the teeth when the index CP or CP + CP or CP does not exceed the average intensity of caries corresponding to the age group; There are no signs of focal demineralization and initial caries identified by special methods.
The second degree of caries activity (subcompensated form) is a condition of the teeth in which the intensity of caries according to the indices kp or kpu + kp or kp is greater than the average intensity value for a given age group by three signal deviations. At the same time, there is no actively progressing focal demineralization of enamel and initial forms of caries.
The third degree of caries activity (decompensated form) is a condition in which the indicators of the CP or CP + CP or CP index exceed the maximum value or, with a lower value of the CP, actively progressing foci of demineralization and initial caries are detected.

Thus, the intensity of caries according to the degree of activity is assessed by the following indicators:

1st degree - index up to 4 (compensated)

2nd degree - index from 4 to 6 (subcompensated)

V. Thermometric study.

Thermometry determines the reaction of tooth tissue to the action of thermal stimuli.

An intact tooth with a healthy pulp reacts painfully to temperatures below 5-10°C and above 55-60°C.

Cold compressed air can be used to test the tooth's response to cold. However, it is sometimes difficult to determine which tooth responds to a thermal stimulus.

It is more objective when a cotton swab, previously immersed in cold or hot water, is brought into the carious cavity or applied to the tooth.

VI. Electroodontometry (EOM).

Using this method, the sensitivity threshold of the dental pulp to electric current is determined, which reflects the viability of the pulp. The minimum current that causes tissue irritation is called the irritation threshold. Electroodontometry is especially important for excluding complicated caries. The method can also be used to check the depth of anesthesia.

The study is carried out from sensitive points: at the incisors from the cutting edge, at premolars and molars from the tubercles.

An intact tooth responds to currents from 2 to 6 μA. With the development of pathological processes, the threshold of irritation (electrical excitability) changes. When the sensitivity threshold of the pulp decreases, the digital indicators increase. A pronounced decrease in the sensitivity of the dental pulp to 35 μA occurs in acute deep caries; up to 70 µA the pulp is viable, and more than 100 µA there is complete necrosis of the pulp. Each tooth is examined 2-3 times, after which the average current strength is calculated.

The method for determining the sensitivity of dental pulp to electric current is quite informative, however, it must be taken into account that its implementation may give a false-negative reaction in the following cases:

for tooth pain relief;
if the patient is under the influence of analgesics, drugs, alcohol or tranquilizers;
with incomplete root formation or its physiological resorption (in these cases, the nerve endings of the pulp are not sufficiently formed or are in the stage of degeneration and respond to a much higher current strength than the pulp of a healthy tooth);
after a recent injury to the tooth (due to pulp concussion);
in case of inadequate contact with enamel (through a composite filling);
with a heavily calcified canal.

In addition, in some cases, there is a decrease in electrical excitability in intact teeth (in wisdom teeth, in teeth that do not have antagonists located outside the arch, in the presence of petrification in the pulp). Inaccurate electroodontometry readings may be due to variability in the blood supply to the pulp, a false reaction due to stimulation of nerve endings in the periodontium during pulp necrosis. In molars, a combination of living and dead pulp in different canals is possible. Results may not be true in persons with mental disorders who are unable to respond adequately to mild pain.

The likelihood of error can be reduced by comparative electroodontometry, simultaneous examination of antimer teeth and other obviously healthy teeth, as well as the placement of electrodes alternately on all cusps of the chewing tooth being studied.

This study strictly contraindicated! persons with an implanted heart pacemaker.

VII. Transillumination.

Transillumination, based on the unequal light-absorbing ability of various structures, is carried out by passing rays of light by “transilluminating” the tooth from the palatal or lingual surface. The passage of light through the hard tissues of teeth and other tissues of the oral cavity is determined by the laws of optics of turbid media. The method is based on the assessment of shadow formations that appear when a cold beam of light, harmless to the body, passes through the tooth. Transillumination is especially effective when illuminating single-rooted teeth.

When examined in rays of transmitted light, signs of caries damage are detected, including “hidden” carious cavities. In the initial stages of the lesion, they usually appear in the form of grains of various sizes from pinpoint to the size of a millet grain and larger, with uneven edges from light to dark color. Depending on the location of the initial caries focus, the transillumination pattern changes. With fissure caries, the resulting image reveals a dark, blurry shadow, the intensity of which depends on the severity of the fissures; with deep fissures, the shadow is darker. On the proximal surfaces, the affected areas have the appearance of characteristic shadow formations in the form of hemispheres of brown light, clearly delimited from healthy tissue. On the cervical and bucco-lingual (palatal) surfaces, as well as on the mounds of chewing teeth, lesions appear in the form of small-sized darkenings that appear against a light background of intact hard tissues.

In addition, when using the method, it is possible to detect the presence of calculus in the tooth cavity and foci of subgingival tartar deposition.

VIII. Luminescent diagnostics.

This method of using ultraviolet irradiation is based on the effect of luminescence of hard dental tissues and is intended for the diagnosis of initial caries and is based.

Under the influence of ultraviolet rays, luminescence of tooth tissue occurs, characterized by the appearance of a delicate light green color. Healthy teeth glow snow-white. Areas of hypoplasia give a more intense glow compared to healthy enamel and give a light green tint. In the area of foci of demineralization, light and pigmented spots, a noticeable quenching of luminescence is observed.

IX. X-ray examination.

It is used when there is a suspicion of the formation of a carious cavity on the approximal surface of the tooth and when the teeth are closely spaced, when the hard tissue defect is inaccessible to inspection and probing. This method is used for all forms of pulpitis, apical periodontitis, as well as for monitoring the filling of root canals after treatment and dynamic monitoring of the apical focus of destruction.

The variety of x-ray research methods requires the dentist to be able to choose a method that provides maximum information regarding the patient being examined.

1. Traditional methods of x-ray examination. The basis of traditional x-ray examination for most dental and periodontal diseases is still intraoral radiography. This method is the simplest and least radiation-safe, using X-ray machines, where the image is recorded on film. There are currently 4 intraoral radiography techniques:

radiography of periapical tissues in isometric projection;
radiography from an increased focal length with a parallel beam of rays;
interproximal radiography;
X-ray in bite.

2. Radiophysiography. For this research method, X-ray machines with a filmless visual inspection system are used. They are called dental computed radiography (DCR) or radiophysiography. The IFR system includes touch sensors that operate in accordance with a computer program that controls image capture and storage. Radiophysiography is superior to conventional radiography in terms of speed, image quality and reduced radiation exposure. The SKR system program allows you to manipulate the resulting image:

4x or more magnification, which allows you to see small details;
local magnification, which allows you to select individual fragments;
highlighting a specific area;
image alignment;
a negative image can be transformed into a positive one;
dye in a range of colors, which makes it possible to determine the density of the fabric;
optimize the contrast of the object being studied;
make the image embossed;
conduct pseudoisometry, that is, obtain a pseudo-volume image.

The program also has a measuring object function, which allows you to take the necessary measurements and enter them as marks directly on the image.

3. Panoramic radiography. This method makes it possible to simultaneously obtain in one image a detailed image of the entire dentition of both the upper and lower jaws. Such an x-ray allows you to obtain a significantly larger amount of information.

4. Orthopantomography. This type of research is based on the tomographic effect. The result is a detailed image of the upper and lower jaws. The study area usually also includes the lower parts of the maxillary sinuses, temporomandibular joints, and pterygopalatine fossa. From the image it is easy to assess the condition of the upper and lower dentition, their relationships, and identify intraosseous pathological formations. From an orthopantomogram it is possible to calculate periapical index, which can have the following values:

1 point - normal apical periodontium,

2 points - bone structural changes indicating pe-

riapecal periodontitis, but not typical for it,

3 points - bone structural changes with some loss

mineral part, characteristic of the apical pe-

rhiodonta,

4 points - clearly visible enlightenment,

5 points - enlightenment with radical spread of co-

nal structural changes.

X.Laboratory research methods.

1. Determination of pH of oral fluid.

To determine pH, 20 ml of oral fluid (mixed saliva) is collected in the morning on an empty stomach.

The pH test is carried out three times, followed by calculation of the average result.

A decrease in the pH of oral fluid with a shift to the acidic side is considered a sign of active progressive dental caries.

An electronic pH meter was used to study the pH of oral fluid.

2. Determination of saliva viscosity.

Mixed saliva is collected after stimulation by ingesting 5 drops of a solution of 0.3 g of pilocarpine in 15 ml of water. Local pilocarpinization can also be carried out by introducing a small cotton swab moistened with 3-5 drops of a 1% pilocarpine solution into the oral cavity for 10 minutes. For the study, take 5 ml of saliva just obtained after collection. Along with saliva viscometry, water testing is carried out.

The viscosity of saliva is judged by the formula:

t 1 — saliva viscometry time

t 2 - water viscometry time

The average value of V is 1.46 with very significant fluctuations from 1.06 to 3.98. A V value above 1.46 is an unfavorable prognostic indicator for caries.

An Oswald viscometer is used, using a capillary 10 cm long and 0.4 mm in diameter. To obtain accurate results, before adding saliva to the viscometer, it is immersed in water at a temperature of 37°C for 5 minutes.

3. Determination of lysozyme activity in saliva.

Parotid and mixed saliva are collected at the same time of day - in the morning. Mixed saliva was collected by spitting into test tubes after preliminary rinsing of the mouth. Parotid saliva was collected after stimulation with citric acid using a special device proposed by V.V. Gunchev and D.N. Khairullin (1981). The saliva under study is diluted with phosphate buffer in a ratio of 1:20, and the secretion of small salivary glands in a ratio of 1:200.

The activity of lysozyme in mixed and parotid saliva is determined by the photonephelometric method according to V.T. Dorofeychuk (1968).

3. Determination of the level of secretory immunoglobulin A in saliva.

Glass plates measuring 9 x 12 cm are covered with a uniform layer of a mixture of “3% agar + monospecific serum”. In the agar layer, holes with a diameter of 2 mm are created with a punch at a distance of 15 mm from one another. The wells of the first row were filled with 2 μl of standard serum using a microsyringe in dilutions of 1: 2, 1: 4, 1: 8. The wells of the next rows were filled with the test saliva. The plates are incubated in a humid chamber for 24 hours at a temperature of +4°C. At the end of the reaction, the diameters of the precipitation rings are measured. The immunoglobulin content was determined relative to the standard secretory immunoglobulin A serum S-JgA.

The level of secretory immunoglobulin A (S-JgA) in mixed saliva is determined by the method of radial immunodiffusion in a gel according to Manchini (1965) using monospecific serum against human secretory immunoglobulin A produced by the Research Institute of Experimental Physics. N.F. Gamaleya.

Mandatory inserts in the medical record of a dental patient

Filling out a dental patient's medical record requires strict adherence to the orders and instructions of the Ministry of Health of the Republic of Tatarstan.

There are three required inserts in a dental patient's medical record.

In accordance with the order of the Ministry of Health of the Republic of Tajikistan No. 2 dated January 10, 1995, the form “Examination of a patient for syphilis” was introduced. When filling out this insert

Attention is drawn to the patient's characteristic complaints. An objective examination involves palpation of the submandibular and cervical lymph nodes. The condition of the mucous membrane of the oral cavity, tongue and lips is especially carefully assessed. The presence of erosions, ulcers and cracks in the corners of the mouth (jam) of unknown etiology requires mandatory referral of the patient for examination for syphilis with a corresponding entry in the chart.

In accordance with the order of the Ministry of Health of the Republic of Tajikistan No. 780 dated August 18, 2005, the “Form for oncological preventive medical examination” was introduced. Particular attention is paid to the condition of the lips, mouth and pharynx, lymph nodes, and skin. If cancer or a precancerous disease is suspected, the “+” symbol is placed in the appropriate column, after which the patient is sent to an oncological treatment facility.

The insert “Dosimetric monitoring of a patient’s ionizing radiation” records radiation doses during X-ray examinations of teeth and jaws. This form was developed on the basis of a sheet for recording patient dose loads during X-ray examinations, which complies with the requirements of SaNPin 2.6.1.1192-03.

Legal registration of the relationship between the institution (doctor) and the patient

After completing the examination of the dental patient, a diagnosis of the disease is established, which should be as complete as possible. In this case, each of the provisions of the diagnosis is substantiated.

This approach allows us to build a coherent system of complex treatment of the patient, taking into account all the factors influencing both the occurrence and development of this disease, as well as its course and prognosis.

The diagnosis is entered into the dental patient’s medical record with an explanation of the possible outcomes of the disease. The treatment plan is explained in detail to the patient, indicating the means and methods of treatment. Alternative treatments may be suggested if available. The timing of treatment and subsequent rehabilitation for this pathology is discussed separately.

The patient has the right to decide whether he agrees or disagrees with the treatment plan proposed to him, about which a corresponding note is made in the medical record.

Informed voluntary written consentfor medical intervention

Voluntary written consent is based on the Law “Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens,” which was adopted by the State Duma of the Russian Federation on July 22, 1993 No. 5487-1, Article 32.

Methodological recommendations of the Federal Compulsory Medical Insurance Fund of Russia dated October 27, 1999 No. 5470/30-ZI determine that the form of patient consent to medical intervention can be determined by the head of a healthcare institution or the territorial body of the Healthcare Administration of a constituent entity of the Russian Federation.

Failure papatient from medical intervention

Refusal of medical intervention is provided for in the Law “Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens,” which was adopted by the State Duma of the Russian Federation on July 22, 1993, No. 5487-1, Article 33.

Methodological recommendations of the Federal Compulsory Medical Insurance Fund of Russia dated October 27, 1999 No. 5470/30-ZI determine that the form of a patient’s refusal of medical intervention can be determined by the head of a healthcare institution or the territorial body of the Healthcare Administration of a constituent entity of the Russian Federation. As an option, a refusal form according to the Moscow City Law Office is offered.

V.Yu. Khitrov,N.I. Shaimieva, A.Kh. Grekov, S.M. Krivonos,

N.V. Berezina, I.T. Musin, Yu.L. Nikoshina

A dental patient's medical record is a document used to identify the patient. The medical record describes the characteristics of the condition and changes in its health.

All medical record data is filled out by a doctor and confirmed by instrumental, laboratory and hardware research data. In addition, the medical record reflects all the features and stages of treatment.

For each dental patient, several documents are drawn up, which include informed voluntary consent for dental treatment, consent to the processing of personal data and a medical record of the dental patient.

We were told about the rules for their registration at the RaTiKa dental clinic (Ekaterinburg).

Medical record of a dental patient

Back on October 4, 1980, by Order of the USSR Ministry of Health No. 1030, form 043/u was approved, which was intended specifically for maintaining records of dental patients.

Dentists were obliged to strictly adhere to this form, but already in 1988 the above order was canceled. Since then, no law has been issued that would order dentists to use a specific form of medical record. However, on November 30, 2009, the Ministry of Health and Social Development of the Russian Federation issued a letter in which it recommended that doctors use the old forms to keep records of their activities (for dentists - 043/u).

Current legislation recommends (but does not oblige) the use of form 043/у for medical records of dental patients. However, it is most convenient to maintain patient records in the appropriate dental management programs.

Most clinics do use this form, but often transform it slightly to a more convenient format, for example, instead of A5 they print in A4 format or make other minor changes.

A dental patient's medical record is completed upon the patient's first visit to the dental clinic. Personal information (full name, gender, age, etc.) is filled out by a nurse or dental administrator, and the rest of the card is filled out exclusively by the attending physician.

Rules for drawing up a medical card for a dental patient by a doctor

The card contains information about the patient’s diagnosis and complaints.
The diagnosis is entered into the chart after the examination.
It is possible to clarify the diagnosis or completely change it. When making amendments, the date must be indicated.
It is important to note the presence of concomitant diseases of the patient or those significant for dental procedures, diseases that he has already suffered.
It is necessary to describe how the current disease develops, include data obtained during an objective study, information about the bite, the condition of the mucous membrane, oral cavity, gums, alveolar processes, and palate.
X-rays and laboratory tests must also be included in the dental patient’s chart.

Each of them should write down their stages of treatment on a separate insert and then place them on the chart.

Rules for storing medical records

The medical card must be kept at all times; it is not given to the patient at home. But we recommend that you give the patient a special form that indicates the date of the next visit. You can develop and release it yourself or use one offered by partner companies, for example, a toothpaste manufacturer.
Considered a legal document, the card must be stored for 5 years from the day when the patient last visited the dentist and a corresponding entry was made about this in the card. The document is then transferred to the archive.
The content of medical records should prevent the possibility of violation of confidentiality and illegal access to them, so it is best to keep them under lock and key.

Informed voluntary consent to dental treatment

Dental services belong to the “List of certain types of medical interventions to which citizens give informed voluntary consent when choosing a doctor and medical organization to receive primary health care,” which was approved on April 23, 2012 by the Ministry of Health and Social Development of the Russian Federation. By signing this document, the patient indicates that he is voluntarily undergoing dental treatment; the need for certain procedures, the plan of which is prescribed in his medical record, was explained in detail to him. The client demonstrates an understanding of possible outcomes, existing risks, and alternative treatment pathways. He knows about the possible accompanying effects of the planned treatment (pain, discomfort, swelling of the face, sensitivity to cold/heat, etc.). The patient also confirms his understanding that the treatment plan may change during the process.

The document can be signed by the patient himself or an authorized representative (if there is a document that confirms the right to represent his interests).

Consent to the processing of personal data

This document gives the organization the right to process the patient’s personal data (full name, date of birth, type of identification document, etc.) in accordance with existing legislation. If the patient is a minor, then consent to the processing of personal data is signed by parents or legal representatives.

All materials are provided by the RaTiKa dental clinic (Ekaterinburg). Text: Elizaveta Gertner

OKUD form code ___________

OKPO institution code ______

Medical documentation

Form No. 043/у

Approved by the USSR Ministry of Health

04.10.80 No. 1030

name of institution

MEDICAL CARD

dental patient

No. _____________ 19... ____________

Full Name ________________________________________________________

Gender (M., F.) ______________________ Age ___________________________________

Address _________________________________________________________________________

Profession _____________________________________________________________________

Diagnosis ________________________________________________________________________________

Complaints ______________________________________________________________________________

Previous and concomitant diseases _____________________________________________

_______________________________________________________________________________

Development of the present disease ________________________________________________

_______________________________________________________________________________

For the printing house!

when preparing a document

A5 format

Page 2 f. No. 043/у

Objective research data, external examination ______________________________

_______________________________________________________________________________

Examination of the oral cavity. Dental condition

Legend: none -

0, root - R, Caries - C,

Pulpitis - P, periodontitis - Pt,

sealed - P,

Periodontal disease - A, mobility - I, II

III (degree), crown - K,

art tooth - I

_______________________________________________________________________________

Bite __________________________________________________________________________

Condition of the oral mucosa, gums, alveolar processes and palate

_______________________________________________________________________________

X-ray and laboratory data ______________________________

_______________________________________________________________________________

Page 3 f. No. 043/у

date		Last name of the attending physician

Treatment results (epicrisis) ___________________________________________________

_______________________________________________________________________________

Instructions ___________________________________________________________________

_______________________________________________________________________________

Attending physician _______________ Head of department _____________________

Page 4 f. No. 043/у

Treatment _______________________________________________________________________

_______________________________________________________________________________

	History, status, diagnosis and treatment when dealing with recurrent diseases	Last name of the attending physician

Page 5 f. No. 043/у

Survey plan	Treatment plan	Consultations

etc. to the end of the page