Making cards. Recommendations for students on filling out a medical record of a dental patient with defects in hard tissues of the teeth Writing an outpatient record of 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 patient data and the course of treatment.

A dental patient card form 043 y is issued to all citizens who have applied for help. The document exists in one copy for each patient. The number of specialists involved in the treatment of the patient does not matter. All data is summarized in 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 a contract for the provision of dental services, which must be signed by the patient after reading the text of the contract. 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 y must contain the patient's passport data. This sheet is filled out at the register. The basis is the documents proving the identity of the applicant. The patient enters information about his health into the card.

Information about the state of health 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, and so on. It is very important to include 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 a visual examination and x-ray studies. The use of an x-ray machine involves irradiation of the patient. The received dose of radiation must also be recorded in the card.

Pages with the results of the examination, data on the diagnosis and the course of treatment are filled in by specialists who carry out the corresponding procedures. The patient must document their consent to the examination and treatment plan.

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

Medical card 043 y is the property of the clinic.

According to the instructions, the dental card form 043 is not handed out. This legal document can be used in the event of litigation and claims from the patient. The card is stored in an outpatient dental facility for 5 years. After this period, the form is transferred to the archive of the organization. The period of storage in the archive is 75 years.

Unlike most established forms of medical forms, form 043 y is advisory. The form can be supplemented and adjusted to the needs of a particular medical institution. It is possible to order such an adjustment of the form in the City Blank printing house, taking into account all the requirements of the customer.

The document can be reduced, supplemented, correct columns. To preserve the protective functions of the document, it is recommended not to exclude important items 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 medical card of a dental patient both in a single copy and 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 card of a dental patient
No. April 27, 2002
Last name, first name, patronymic: Ivanov Ivan Ivanovich Gender husband. Moscow address. Age: 01.10.1966
Contact phones: 452-17-73 Profession: teacher. Diagnosis: 1 1 Medium caries Complaints about the presence of a cavity, write, pain from temperature stimuli (indicate a change in tooth color, aesthetic defect). Past and concomitant diseases: considers himself healthy, or: concomitant somatic cytology (hypertension, allergic reactions, head trauma, heart disease, lung disease, hepatitis, venereal

Examination of the oral cavity. Condition of the teeth. Symbols: absent -
O, root - ?, caries - C, pulpitis - P, periodontitis-sealed - P, paradontosis - A, mobility - I, II, III (degree), crown - K, suit. tooth - I

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

mild illnesses, etc.: acute conditions at the time of treatment!
The development of the present disease: he turned to the clinic, specify: for consultative help with oral cavity sanitation, in connection with the appeared cavity, in connection with the arisen aesthetic defect, painful sensations.
Objective examination 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 and color is not changed (changed). folds easily 1 does not fold). Lymph nodes are not palpable (lt; palpable). 1-3 enlarged up to 0.5 cm in diameter, mobile, softly elastic consistency (dense and immobile)
Dental deposits, their localization and quantity:
Occlusion (specify which) orthognathic
The condition of the oral mucosa, gums, alveolar processes and palate: Pale pink, moderately moist, or: hyperemic (cyanotic) and swollen in the area of ​​all teeth or a group of teeth. bleeds pggt; and dotragipaniya.

X-ray laboratory data Date (day, month, year).
On the visiogram 11 there is a defect in the coronal part 11, in the region of the medial angle. The ratio of the carious cavity to the cavity of the tooth, the state of the periodontal gap; osteoporosis or osteoporosis of the bone tissue surrounding the causative tooth, the presence of areas of bone tissue similar in density to the tissues of the tooth, the presence of cavities or other formations in the examined part.
Dear patient!
General diseases can affect the treatment process at the dentist, so please fill out this questionnaire carefully.
We guarantee that the information provided by you in the questionnaire will be used only for the selection of treatment taking into account your health and will not be available to unauthorized persons.
«*- QUESTIONNAIRE (to be filled in by the patient)
I report the following about my state of health:
Last visit to the dentist
(Specify month and year.)
Not really

1. Allergy (drug, food, others)

Symptoms
What stops an attack

1. Blood group_ Rh factor
2. Do you suffer from diseases:

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

1. Do you suffer from:

• high blood pressure
• low blood pressure

1. Do you have seizures, fainting, dizziness
2. Prolonged bleeding after cuts
3. Diabetes
4. Pregnancy
5. Medications taken (specify)
6. Have you had a head injury
7. Transferred hepatitis
8. AIDS, sexually transmitted diseases
9. Recurrent mouth ulcers, herpes
10. Bruxism (nighttime teeth grinding)
11. Diseases of the maxillary sinuses
12. Do you use drugs
13. Do you smoke

19.
I sincerely answered all the points of the questionnaire, I would like to additionally inform about the state of my health the following:
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 I start seeing a dentist, I must tell the doctor about it.
« » 200_ Patient's signature
CONTRACT FOR RENDERING DENTAL SERVICES No.
Option A. Survey contract
« » 200_
We, the undersigned, referred to in
hereinafter CONTRACTOR, represented by the General Director
acting on the basis of the Charter,
licenses No. from "_" 200_g. for the provision of medical services
Decrees of the Government of the Russian Federation of January 13, 1996 No. No. 27 with one
sides, and

1. The contractor undertakes to instruct the doctor.

(F. I. O. of the doctor)

1. Carry out an interview and examination of the CUSTOMER at the time agreed with the CUSTOMER to establish a preliminary diagnosis, the amount of necessary treatment and fully inform the CUSTOMER about the results of the examination, reflecting the preliminary diagnosis and treatment plan in the CUSTOMER's outpatient card. The ambulance
   On the card, the CUSTOMER makes a written note about familiarization with the preliminary diagnosis, treatment plan and possible complications.
2. The CUSTOMER undertakes to pay the cost of the actions provided for in clause 1.1 of this agreement at the rates of the price list, with which the CUSTOMER has previously familiarized himself.
3. The CUSTOMER agrees that during the preview it may be necessary to conduct additional (special

• socialized) 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 contract
" " 200 g.
We, the undersigned,
hereinafter referred to as the CONTRACTOR, represented by the General Director acting
on the basis of the Charter, license No. dated "" 200 for an eye
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 concluded this agreement as follows:

1. The CONTRACTOR undertakes:
1. In accordance with the preliminary diagnosis and treatment plan entered in the outpatient card of the CUSTOMER (clause 1.1 of the contract No. / A dated 200_)
2. doctor,

(Full name of the doctor)
which is obliged to provide the highest quality and most painless methods of treatment in accordance with medical indications, with the use of painkillers if necessary.

1. In the event of an unforeseen absence of the attending physician on the day appointed for treatment, the CONTRACTOR has the right to appoint another doctor for treatment.
1. The CUSTOMER undertakes:
1. follow all instructions of the attending physician and medical personnel.
2. Arrive for treatment at the scheduled time agreed with the doctor.
3. Maintain good oral hygiene and attend scheduled medical check-ups.
4. Make payment for medical services at the prices of the price list, which the CUSTOMER got acquainted with before concluding this agreement.
2. The CUSTOMER agrees that special types of treatment will be carried out by the appropriate specialists of the CONTRACTOR.
3. The CONTRACTOR shall be liable in case of non-fulfillment or poor-quality fulfillment of its obligations in the presence of its own fault.
4. In case of disagreement between the CONTRACTOR and the CUSTOMER regarding the quality of the 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 of the territorial organizations of the Dental Association (All-Russian) in the prescribed manner.
5. Other conditions for all types of dental services, except for periodontics, there is a 36-month warranty, provided that the CUSTOMER regularly visits the CONTRACTOR for preventive examinations at least once every 6 months.

CONTRACTOR CUSTOMER
(Full name of the patient)

MAP MAINTENANCE SAMPLE

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

Medium caries
Complaints: for short-term pain from cold, sweet, for the presence of a cavity. Specify the formula of the tooth.
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-dentine border. Short-term pain from thermal stimuli. Percussion is negative.
Treatment: Under application 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 is medically treated (specify with what). On the (name) of the surface, 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, ingestion of food, short-term pain from temperature stimuli in (indicate the formula of the tooth).
Objectively: on the (name) surface (indicate the formula of the tooth) 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 thermal stimuli. Percussion is negative.
Treatment: Under application anesthesia, the drug, concentration, dose and infiltration (conduction) anesthesia name, adrenaline concentration and dose formed and drug treated (specify with what) the cavity according to (specify) class. The bottom is light
(weakly pigmented), dense. Therapeutic pad (name). Insulating gasket (name). On the (name) of the 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's signature

Analysis of radiographs

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

The classification of caries used in Russia is based on a topographical feature, although the priority is recognized for 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 with the formation of a cavity.

^ CARIES IN THE SPOT STAGE or carious demineralization

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

EXAMINATION:

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

^

The goal of treatment is to stabilize the carious process.

Cleansing of the affected enamel surface with Radent prophylactic paste;

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

Treatment of spots localized in areas visible when smiling with the preparation "Stangard", fluorine varnish - "Composil";

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

1) the disappearance of enamel stains

2) restore the gloss of the enamel surface in the affected area.
^

II. SURFACE CARIES

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 area of ​​fissures.

EXAMINATION:

inspection, probing, staining with "Caries Detector".

^

Cleansing the surface of the 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", "Lyziks", "Clearfil".

Dentin protection - materials "Composil", "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 a superficial lesion in the area of ​​the fissure, it is necessary to treat the surface with Saforide, Composil preparations and carry out dynamic monitoring during repeated examinations every 3 months.

With positive dynamics, seal the fissures with the Titmate sealant.

Requirements for the results of treatment:

Absence of recurrent caries at the border of "tooth tissue - filling";

Stabilization of the process in the area of ​​fissures.
^

III. MEDIUM CARIES

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

EXAMINATION:

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

^ CHARACTERISTICS OF MEDICAL MEASURES:

Anesthesia (and filtration, conduction, etc.)

Surface cleaning with Radent paste;

cavity preparation with removal of necrotic and pigmented tissues;

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

When filling the material "Citrix" there is no need to apply a gasket and etching;

Imposition of filling material "Clerafil", "Lyziks".

Requirements for the results of treatment:

Lack of hypersensitivity to temperature, mechanical and chemical stimuli;

^

IV. DEEP CARIES

A significant spread of the process to the dentin of the tooth is characteristic.

EXAMINATION:

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

^ CHARACTERISTICS OF MEDICAL MEASURES.

In case of difficulties in diagnosis - the imposition of a diagnostic seal.

Carrying out anesthesia

Removal of overhanging enamel and softened dentin

Imposition of medical pads "Cimex", "Lika", "Liner Bond".

Imposition of a temporary bandage with the material "Cimex".

Evaluation of the preparation quality by the "Caries Detector";

With the diagnosis of "Deep caries":

Conducting anesthesia;

Carrying out the preparation;

Checking the quality of the preparation with the "Caries Detector";

The imposition of medical pads from the materials "Lika", "Cimex", "Liner Bond";

Applying an insulating gasket "Cimex", "Lika";

Dentin protection - varnishes or gaskets "Composil", "Cimex", "Lika";

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

Application of filling material "Cntrix"

Requirements for the results of treatment:

No hypersensitivity

Absence of recurrent caries;

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

V. PREVENTIVE SEALING OF DENTAL FISSURES

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

SURVEY

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

^ EVENT DESCRIPTION

Fissure cleansing with Radent paste;

Fissure sealing with Titmate sealant or treatment with Saforide.

Requirements for sealing results:

No carious lesions of fissures.

^ VI. COMPLICATIONS OF CARIES

VI. I Pulpitis

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

EXAMINATION:

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

^ CHARACTERISTICS OF MEDICAL MEASURES:

Anesthesia

Pulp removal under anesthesia or with preliminary application of devitalizing agents: arsenic paste;

Mechanical and drug treatment of root canals using sodium hypochlorite solution "Neocletzner Sikain";

Root canal filling with Vitapex paste and other types of pastes with gutta-percha;

The imposition of an insulating gasket;

With a significant curvature of the root canals and in other cases when complete removal of the pulp is impossible, the mummifying preparation "Neo Triozinc Pasta" should be used.

Requirements for the results of treatment:

The cessation of pain;

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

VI. II^ Apical periodontitis

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

EXAMINATION:

questioning, examination, instrumental examination, X-ray examination.

^ CHARACTERISTICS OF THERAPEUTIC MEASURES IN THE CONSERVATIVE TREATMENT OF APICAL PERIODONTITIS:

In the acute period - anesthesia

Preparation and opening of the tooth cavity;

Removal of the contents of the root canal and exudate with abundant washing with antiseptic solutions;

Mechanical treatment of the root canal using EDTA;

In the treatment of 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; compulsory rinsing;

After stopping the acute process and in the presence of a chronic process in the presence of zones of periapical bone tissue destruction, temporary root canal obturation should be applied using osteotropic preparations: "Iodo-glycol paste".

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

Obturation of the root canal with the use of material "Vitapeks" if necessary - in combination with gutta-percha;

The imposition of an insulating gasket "Cimex";

Placement of a permanent filling.

Requirements for the results of treatment:

The cessation of pain;

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

^ Superficial caries

There are no complaints. Came in for a dental cleaning. Objectively: a carious cavity on the medial surface of the 16th tooth is located in the center of an extensive chalky spot, within the enamel.

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

Objectively: a carious cavity on the masticatory surface within the enamel, probing is painless; EOD=3 uA.

Diagnosis: superficial caries of the 16th tooth.

Treatment: preparation of a carious cavity, drug treatment with 3% sodium hypochlorite solution, filling from KPM Valux plus.

^

Medium caries

There are no complaints. Came in for a dental cleaning. Objectively: a carious cavity on the chewing surface of the 27th tooth is within its own dentin, filled with pigmented dentin, probing is painful along the enamel-dentin border.

Treatment: preparation of a carious cavity, drug treatment with 3% sodium hypochlorite solution, filling from KPM Valux plus.

Complaints of short-term pain when eating sweet food.

Objectively: there is 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; EOD=5 uA.

Diagnosis: average caries of the 27th tooth.

Treatment: preparation of a carious cavity, drug treatment with 3% sodium hypochlorite solution, filling from KPM Valux plus.

Complaints of short-term pain when eating.

Objectively: there is 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. Dissection syndrome positive (dissection is painful)

Diagnosis: average caries of the 27th tooth.

Treatment: preparation of a carious cavity, drug treatment with 3% sodium hypochlorite solution, filling from KPM Valux plus.
^

deep caries

Complaints about a fast-passing pain in the 46th tooth during a meal. Objectively: there is a deep carious cavity on the masticatory surface of the 46th tooth within the peripulpal dentin, probing is painless; EOD=8 uA.

Complaints of short-term pain from temperature stimuli.

Objectively: on the chewing surface of the 46th tooth there is a deep

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

Diagnosis: deep caries of 46 tooth.

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

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 mollusk-pulpal dentin, probing is painful throughout the bottom, the dentin is dense, there is no communication with the pulp chamber.

Diagnosis: deep caries of 46 tooth.

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

PULPITS

^ Acute focal pulpitis

Complaints of a sharp pain in the 18th tooth for 2 days. Objectively: in the 18th tooth there is a deep carious cavity within the ojuolo-pulpal dentin, filled with softened dentin, probing is painful in the area of ​​the projection of the medial horn of the pulp, 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, a carious cavity was prepared, medicated with 3% sodium hypochlorite on the bottom, calcium hydroxide (Dycal), a gasket (Dyract), a filling from CPM 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 ​​projection of the medial horn of the pulp, 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, a carious cavity was prepared, drug treatment was carried out with 3% sodium hypochlorite solution, calcium hydroxide (Dycal), a gasket (Dyract), a filling from KPM Valux plus were placed on the bottom.

Acute diffuse pulpitis

Complaints of paroxysmal nocturnal pain in the region of the upper jaw on the left.

Objectively: there is a deep carious cavity on the chewing surface of the 26th tooth 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, the preparation of the carious cavity, the opening of the tooth cavity, deep amputation of the coronal and extirpation of the root pulp, the expansion of the root canals and drug treatment with 3% sodium hypochloride solution, the filling of the root canals AN-26 were carried out. Temporary filling. Direction for control radiography.

On the radiograph dated May 16, 2005, the root canals of the 26th tooth were sealed to the physiological tops. Filling from KPM Herculite XRV.

Complaints about a sharp paroxysmal, long-lasting pain from a hot temperature stimulus. Cold pain The tooth has not hurt before.

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

Diagnosis: acute diffuse pulpitis of the 26th tooth.

Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml, the carious cavity was prepared, the tooth cavity was opened. deep amputation of the coronal and extirpation of the root pulp, expansion of the root canals and drug treatment with 3% solution of hypochlorite 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. Direction for control radiography.

On the radiograph dated May 17, 2005. the root canals of the 26th tooth were sealed to the physiological tops. Filling from KPM Herculite XRV.

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

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

Diagnosis: acute diffuse pulpitis of the 26th tooth.

Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml, the filling was removed, the tooth cavity was opened, deep amputation of the coronal pulp and extirpation of the root pulp, expansion of the root canals and drug treatment with 3% sodium hypochlorite solution, root canal filling AN-26. Temporary filling. Direction for control radiography. On the radiograph dated May 18, 2005. the root canals of the 26th tooth were sealed to the physiological tops. Filling from KPM Herculite XRV.

Chronic fibrous pulpitis

There are 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% carious cavity preparation, deep amputation of the coronal pulp and extirpation of the root pulp, mechanical expansion of the root canals, drug treatment with 3% sodium hypochlorite solution, root canal filling AN-26. Temporary filling. Direction for control radiography.

On the radiograph dated May 19, 2005, the root canals of the 26 tooth were sealed to the physiological tops. Filling 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 masticatory 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; EOD = 40 µA.

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

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

On the radiograph dated May 20, 2005, the root canals of the 26th tooth were sealed to the physiological tops. Filling from KPM Valux plus.

Complaints of pain during meals at contrasting temperatures.

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

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

On the radiograph dated May 21, 2005, the root canals of the 26 tooth were sealed to the physiological tops. Filling from KPM Herculite XRV.

Complaints of aching pain during meals of contrasting temperatures and the transition of their cold room to a warm one.

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

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

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

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 card of a dental patient" refers to medical documentation, form No. 043 / y, which is indicated on the front page of the form. Prior to the start of the patient's medical history, the front side of the card indicates the official name of the medical institution, the registration number is affixed and the date of its compilation is noted.

Dental diseases are one of the most common pathologies that makes you seek help from a dentist.

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

The most complete information allows you to correctly diagnose the disease, effectively plan complex treatment and prevention. The doctor receives the necessary set of differential diagnostic indicators with a thorough history taking, a detailed clinical examination, using additional examination methods and laboratory research methods.

When filling out a medical record of a dental patient, it is necessary to take into account the "Medical and 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, where "guidelines for filling out a medical record of a dental patient" are approved.

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

Diagram of the medical history

General information (Personal data).

1. Surname, name, patronymic of the patient

2. Age, year of birth

4. Place of work

5. Position held

6. Home address

7. Date of contacting the clinic

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

I.Patient's complaints.

1. Main complaints.

These are complaints that disturb 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) spontaneous or causal pain;

c) the cause of the appearance or intensification of pain;

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

e) duration of pain (periodic, paroxysmal, constant

f) the presence or absence of night pain;

g) the presence or absence of irradiation of pain, the zone of irradiation;

h) the duration of pain attacks and light intervals;

i) factors that relieve pain;

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

no lei, then indicate that the diseased tooth was found during the examination);

k) whether there were exacerbations, what are their causes.

2. Additional complaints

These are data that are not associated with the main complaints and are usually the result of some somatic disease. Additional complaints are detected actively, according to the scheme, in a certain sequence:

2.1 Digestive organs.

1. Feeling of dryness in the mouth.

2. The presence of increased salivation.

3. Thirst: how much liquid he drinks 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 (solid, liquid).

6. Bleeding from the oral cavity: spontaneous, when brushing teeth, when taking hard food, absent.

7. The presence of bad breath.

3. Complaints that determine the general condition

General weakness, malaise, unusual fatigue, fever, decreased performance, weight loss (how much and for what period).

II.History of present illness.

The emergence, course and development of a real 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 disease with.

3. The onset of the disease is acute or gradual.

4. First symptoms.

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

6. Diagnostic and therapeutic measures according to the medical history (old radiographs, entries in the outpatient card, etc.). What was the diagnosis. Duration and effectiveness of previous treatment.

7. Characteristics of the period preceding the present appeal to the clinic of therapeutic dentistry. Whether he was registered at the dispensary, whether he 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 relationship of the disease with external factors, living conditions, past diseases.

1. Place of birth.

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

3. Labor history: when he 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 room (temperature, its fluctuations, drafts, dampness, nature of lighting, dust, contact with harmful substances). Mode of work (day work, shift work, duration of the working day). The psychological atmosphere at work and at home, the use of days off, holidays.

4. Living conditions at the moment.

5. The nature of the food (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 intoxication: smoking (from what age, the number of cigarettes per day, what he smokes); the use of alcoholic beverages; other bad habits

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

8. Diseases of the next of kin. The state of health or cause of death (with indication of 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. Make a genetic picture.

9. Tolerance of medicinal substances. Allergic reactions.

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

Physical examination data

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

I. Inspection.

On examination pay attention to:

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

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

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

4. Behavior of the patient (sociable, calm, irritable, negative).

5. The presence or absence of asymmetry.

6. The condition of the red border of the lips and corners of the mouth.

7. Degree of mouth opening.

8. Speech of the patient (intelligible, slurred)

9. Skin and visible mucous membranes:

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

10. Lymph nodes:

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

II. Plan and sequence of examination of the oral cavity.

A healthy person has a symmetrical face. The lips are quite mobile, the upper one does not reach the cutting edges of the upper front teeth by 2-3 mm. The opening of the mouth, the movement of the jaws are free. Lymph nodes are not enlarged. Actually the mucous membrane of the mouth is pale pink or pink, does not bleed, fits snugly to the teeth, painless.

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

Inspection usually begins with the right half of the upper jaw, then examine its left side, the lower jaw on the left; finish inspection on the right side in the retromolar area of ​​the mandible.

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 threshold is considered shallow if its depth is not more than 5 mm, medium - 8-10 mm, deep - more than 10 mm.

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

When assessing the dentition, attention is paid to the type of occlusion: orthognathic, prognathic, progynical, micrognathia, straight. Separately, the uniformity of the closing of the teeth and the presence of dentoalveolar anomalies, diastema and three are noted.

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

III. The most common clinical tooth designation systems.

1. Standard Zigmandy-Palmer square-digital system. It provides for the division of the dentition (dentition) into 4 quadrants along the sagittal and occlusal planes. When recording in the map, each tooth is indicated by a graphic, 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 this sequence: from the right upper to the right lower jaw.

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

5. Designations of the oral cavity. For this, 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 back teeth

sextant 04 - upper canines and incisors

sextant 05 - upper left back teeth

sextant 06 - lower left back teeth

sextant 07 - lower canines and incisors

sextant 08 - lower right posterior teeth.

V. Designations of various types of lesions of the teeth.

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. Sounding.

This procedure is carried out using a dental probe. This allows you to make a judgment about the nature of the enamel, to 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, the state 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 infiltrate on the alveolar process or along the transitional fold.

Additional research methods

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

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

An important role in diagnosing and predicting the effectiveness of therapeutic and preventive measures in dentistry is played by determining the level of oral hygiene. To assess the hygienic state of the oral cavity, it is recommended to calculate the following hygienic indices (IGIR).

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

1.1. Quantification is carried out according to a five-point system:

staining of the entire surface of the tooth - 5 points,

3/4 surface - 4 points,

1/2 surface - 3 points,

1/4 surface - 2 points,

no staining - 1 point.

The hygienic condition is considered good if the quantitative value of the index is 1.0 points, if the value is 1.1-2.0 it is satisfactory, if the value is 2.1-5.0 it is unsatisfactory.

1.2. Qualitative assessment:

no staining - 1 point,

weak staining - 2 points,

intense staining - 3 points.

The hygienic state is considered good if the index value is 1 point, if the value is 2, it is satisfactory, if the value is 3, it is unsatisfactory.

2. Hygiene index Green & Vermillion (in the card is written: IG GV). According to the methodology of the authors, a simplified hygiene index (OHI-S) is determined, which includes an index of plaque and an index of tartar.

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

0 - no staining;

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

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

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

2.2. 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 from one surface of the examined tooth and covers up to 1/3 of the crown height;

2 points - supragingival calculus covers the tooth from 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

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

The combined Green-Vermillion index is calculated as the sum of the plaque and calculus indices. The calculation of each of the indicators is carried out according to the formula:

By Wed = K and / n

Kav - general indicator of cleanliness of teeth

K and - an indicator of the degree of coloring of one tooth

n is the number of examined teeth

The hygienic condition is considered good when the index value is 0.0, when the value is 0.1-1.2 it is satisfactory, when the value is 1.3-3.0 it is unsatisfactory.

To assess this index, the vestibular surfaces of the 16th, 11th, 26th, and 31st teeth and the lingual surfaces of the 36th and 46th teeth are stained. The examined surface of the tooth is conditionally divided into 5 sections: central, medial, distal, mid-occlusal, mid-cervical. In each of the sections, an assessment is made in points:

0 points - no staining

1 point - staining of any intensity

The hygiene efficiency index is calculated by 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 .

The determination of the formation rate is carried out by staining the following surfaces of teeth (tooth) with Lugol's solution. First, a controlled cleaning of the surfaces of the examined teeth is carried out. In the future, within 4 days of the examined teeth, and then repeated staining of the surfaces of the same teeth is carried out.

The assessment of the degree of coverage of these surfaces with soft plaque is carried out according to a five-point system. The difference between the indicators of staining with Lugol's solution of the surfaces of the examined teeth between 4 and 1 days reflects the rate of its formation.

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

II. Vital staining of hard tissues of the tooth.

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. As a dye, a 2% aqueous solution of methylene blue is usually used.

To prepare a solution of methylene blue, 2 g of the dye is added to a 100 ml volumetric flask and topped up to the mark with distilled water.

The surface of the teeth to be examined is carefully cleaned of soft dental deposits with a swab moistened with a 3% hydrogen peroxide solution. 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 tooth surface with cotton swabs or by rinsing.

According to E.V. Borovsky and P.A. Leus (1972) distinguished light, medium and high degree 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 stained color strip was taken as 10%, and the most saturated - for 100% (Aksamit L.A., 1974).

In order to determine the effectiveness of the 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 the enamel can be judged by the composition of the hard tissues of the teeth, their hardness, resistance to acids and other indicators. In clinical conditions, methods for assessing the resistance of hard tooth tissues to the action of 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 estimated by the intensity of its staining with 1% methylene blue solution.

The etched area turns blue. The degree of staining reflects the depth of damage to the enamel and is assessed using a reference polygraphic blue scale. The more intensively the etched area is stained (from 40% and higher), 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., Leontiev V.K., Redinova T.L. et al., 1989). Based on an assessment of both the state of tooth enamel and the remineralizing properties of saliva.

The enamel surface of the examined tooth is thoroughly cleaned of plaque with a dental spatula and 3% hydrogen peroxide solution, dried with compressed air. Then a drop of hydrochloric acid buffer pH 0.3-0.6 is always applied to it at 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 ​​\u200b\u200bthe tooth enamel for 1 minute. Enamel susceptibility to acid action is estimated by the intensity of staining of the etched area of ​​tooth enamel. After 1 day, re-staining of the etched area of ​​tooth enamel is carried out without re-exposure to the demineralizing solution. If the etched area of ​​the tooth enamel is stained, then this procedure is repeated again after 1 day. The loss of the ability to be stained by the etched area 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 bring the volume to 200 ml with distilled water. To give greater viscosity to one part of the specified solution add one part of glycerol. The increased viscosity contributes to obtaining its drops with a constant value of contact with the tooth and better retention on the surface. For better visual control, the demineralizing liquid is tinted with acid fuchsin. In this case, the demineralizing solution acquires a red color.

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. The resistance of people to caries is characterized by low susceptibility of tooth enamel to the action of acid (below 40%) and high remineralizing ability of saliva (from 24 hours to 3 days), while caries-prone teeth are characterized by high susceptibility of tooth enamel to the action of acid (above or equal to 40%) and low remineralizing ability of saliva (more than 3 days).

IV. The index of the intensity of tooth decay by caries.

The intensity of caries is determined by the average number of carious teeth per 1 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 (CPU)
indicators
		from 35 years to 44 years
very low
low
moderate
high
very high	6.6 or more	16.3 and over

In childhood, in order 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 occlusion), 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 kp or KPU + kp or KPU does not exceed the indicators of the average intensity of caries of the corresponding 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 KPU is more than the average intensity value for this age group by three signal deviations. At the same time, there is no actively progressive 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 indices kp or KPU + kp or KPU exceed the maximum value or, with a lower value of KPU, actively progressing foci of demineralization and initial caries are detected.

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

1 degree - index up to 4 (compensated)

2 degree - index from 4 to 6 (subcompensated)

V. Thermometric study.

With thermometry, the reaction of tooth tissues to the action of thermal stimuli is determined.

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 reaction of the tooth to cold. However, it is sometimes difficult to determine which particular tooth reacts to a thermal stimulus.

More objectively, 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 threshold of sensitivity 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 to exclude complicated caries. The method can also be used to test the depth of anesthesia.

The study is carried out from sensitive points: in incisors from the cutting edge, in 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 (electroexcitability) changes. When the threshold of sensitivity of the pulp is lowered, the digital indicators increase. A pronounced decrease in the sensitivity of the dental pulp to 35 μA occurs with acute deep caries; up to 70 µA, the pulp is viable, and more than 100 µA, 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 the tooth pulp to an electric current is quite informative, however, it must be borne in mind that its implementation can give a false negative reaction in the following cases:

• when anesthesia of the tooth;
• if the patient is under the influence of analgesics, drugs, alcohol or tranquilizers;
• with incomplete formation of the root 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 this tooth (due to pulp concussion);
• in case of inadequate contact with the 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 standing outside the arch, in the presence of petrificates in the pulp). Inaccurate indications of electroodontometry may be due to the variability of 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 live and dead pulp is possible in different canals. Results may be inconsistent in individuals with psychiatric disorders who are unable to adequately respond to mild pain.

The probability of error can be reduced by comparative electroodontometry, simultaneous examination of antimer teeth and other obviously healthy teeth, as well as the location of electrodes alternately on all mounds of the examined chewing tooth.

This study absolutely contraindicated! persons who have an implanted pacemaker.

VII. Transillumination.

Transillumination, based on the unequal light-absorbing ability of various structures, is carried out by passing rays of light, by “seeing through” the tooth from the palatal or lingual surface. The passage of light through the hard tissues of the teeth and other tissues of the oral cavity are 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 passes through the tooth, which is harmless to the body. Transillumination is especially effective when transilluminating single-rooted teeth.

In the study in the rays of transmitted light, signs of caries damage are found, including "hidden" carious cavities. In the initial stages of the lesion, they usually appear as grains of various sizes from punctate to the size of a millet grain and more, with uneven edges from light to dark in color. Depending on the localization of the source of initial caries, the transillumination pattern changes. With fissure caries, a dark blurry shadow is revealed in the resulting image, the intensity of which depends on the severity of the fissures, with deep fissures the shadow is darker. On the proximal surfaces, the lesions have the appearance of characteristic shadow formations in the form of hemispheres of brown light, clearly demarcated from healthy tissue. On the cervical and buccal-lingual (palatine) surfaces, as well as on the mounds of the masticatory teeth, there are lesions in the form of small blackouts that appear against a light background of intact hard tissues.

In addition, during the use of the method, it is possible to detect the presence of a 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 on.

Under the influence of ultraviolet rays, luminescence of tooth tissues 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 ​​demineralization foci, light and pigmented spots, a noticeable quenching of luminescence is observed.

IX. X-ray study.

It is used in case of suspicion of the formation of a carious cavity on the proximal surface of the tooth and with a close arrangement of teeth, when a defect in hard tissues is not available for examination and probing. This method is used in all forms of pulpitis, apical periodontitis, as well as to control root canal filling after treatment and dynamic observation 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 diseases of the teeth and periodontium is still intraoral radiography. This method is the simplest and least safe in terms of radiation, using x-ray machines, where the image is fixed on the film. Currently, there are 4 methods of intraoral radiography:

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

2. Radiophysiography. For this research method, X-ray machines with a filmless visual control system are used. They are called dental computed radiography (TFR) or radiophysiography. The TFR 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 reduction in radiation exposure. The TFR system program allows you to manipulate the resulting image:

• magnification by 4 times or more, which allows you to consider fine details;
• local magnification, which allows you to select individual fragments;
• highlighting a specific area;
• image alignment;
• a negative image can be translated into a positive one;
• paint in a color scheme, which makes it possible to determine the density of the fabric;
• optimize the contrast of the object under study;
• make the image embossed;
• to carry out pseudo-isometry, that is, to obtain a pseudo-volumetric image.

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

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

4. Orthopantomography. This type of study is based on the tomographic effect. The result is a detailed image of the upper and lower jaws. The lower sections of the maxillary sinuses, temporomandibular joints, and pterygopalatine fossae usually also fall into the study area. From the picture it is easy to assess the condition of the upper and lower dentition, their relationship, to identify intraosseous pathological formations. Orthopantomogram can be used to calculate periapical index, which can have the following values:

1 point - normal apical periodontium,

2 points - bone structural changes indicating ne-

riapecal periodontitis, but not typical for it,

3 points - bone structural changes with some loss

mineral part, characteristic of the apical

rhyodont,

4 points - well-visible enlightenment,

5 points - enlightenment with a radical spread of co-

stnyh structural changes.

x.Laboratory research methods.

1. Determination of the pH of the oral fluid.

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

The study of pH is performed three times, followed by the calculation of the average result.

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

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

2. Determination of saliva viscosity.

Mixed saliva is taken after stimulation by ingestion of 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 into the oral cavity for 10 minutes a small cotton swab moistened with 3-5 drops of a 1% solution of pilocarpine. For research, take 5 ml of saliva just obtained after sampling. Along with viscometry of saliva, a study of water 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 the activity of lysozyme in saliva.

Parotid and mixed saliva is taken at the same time of day - in the morning. Mixed saliva was collected by spitting into test tubes after prerinsing 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 studied saliva 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. Dorofeichuk (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". Holes with a diameter of 2 mm are created in the agar layer 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 studied saliva. The plates are incubated in a humid chamber for 24 hours at +4°C. At the end of the reaction, the diameters of the precipitation rings are measured. The content of immunoglobulin 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 the gel according to Manchini (1965) using monospecific serum against human secretory immunoglobulin A produced by the NIIE. N.F. Gamaleya.

Mandatory inserts in the medical record of a dental patient

Filling in the medical record of a dental patient requires strict compliance with the orders and instructions of the Ministry of Health of the Republic of Tatarstan.

There are three mandatory inserts in the medical record of a dental patient.

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

Attention is drawn to the characteristic complaints of the patient. An objective examination involves palpation of the submandibular and cervical lymph nodes. The condition of the oral mucosa, tongue and lips is especially carefully assessed. The presence of erosions, ulcers and cracks in the corners of the mouth (zaed) of unclear etiology requires a mandatory referral of the patient for examination for syphilis with an appropriate entry in the card.

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

The insert "Dosimetric control of ionizing radiation of a patient" records the doses of radiation during x-ray examinations of teeth and jaws. This form was developed on the basis of the sheet for recording the patient's radiation exposure 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. At the same time, each of the provisions of the diagnosis is substantiated.

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

The diagnosis is entered into the medical record of the dental patient 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 offered, if available. The terms of treatment and subsequent rehabilitation for this pathology are discussed separately.

The patient has the right to decide whether he agrees or disagrees with the proposed treatment plan, which is indicated 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 FFOMS of Russia dated October 27, 1999 No. 5470/30-ZI determine that the form of the patient's consent to medical intervention can be determined by the head of the healthcare institution or the territorial body of the Healthcare Department of the constituent entity of the Russian Federation.

Failure pabenefit 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 a territorial body of the Healthcare Administration of a constituent entity of the Russian Federation. It is proposed, as an option, a form of refusal according to the UZ of Moscow.

V.Yu. KhitrovN.I. Shaimiev, A.Kh. Grekov, S.M. Krivonos,

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

The medical record of a dental patient is a document for identifying a patient. The medical card describes the features of the condition and changes in his health.

All data of the medical record are filled in by the doctor and confirmed by the data of instrumental, laboratory and hardware studies. 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 to 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 (Yekaterinburg).

Medical card of a dental patient

As early as October 4, 1980, Form 043 / y was approved by Order of the Ministry of Health of the USSR No. 1030, which was intended specifically for maintaining records of dental patients.

Dentists were required to strictly adhere to this form, but already in 1988 the above order was canceled. Since then, no law has been issued to 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 / y).

The current legislation recommends (but does not oblige) the use of form 043 / y for medical records of dental patients. However, it is most convenient to keep patient records in the appropriate programs for managing dentistry.

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

The medical card of a dental patient is filled out at the first visit of the patient to the dental clinic. Personal data (name, gender, age, and so on) are filled in by a nurse or dental administrator, and the rest of the card is filled out exclusively by the attending physician.

Rules for issuing a medical card for a dental patient by a doctor

1. The card contains information about the diagnosis and complaints of the patient.
2. The diagnosis is entered into the card after the examination.
3. It is possible to clarify the diagnosis or completely change it. When making amendments, the date must be indicated.
4. 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.
5. It is necessary to describe how the current disease develops, to include data obtained during an objective study, information about the bite, the condition of the mucous membrane, oral cavity, gums, alveolar processes, and palate.
6. X-rays, laboratory tests must also be in the dental patient's chart.

Each of them should record their stages of treatment on a separate insert and then place them on the card.

Rules for storing medical records

• The medical card must always be in, it is not issued to the patient at home. But we recommend that you give the patient a special form with you, which indicates the date of the next visit. You can develop and release it yourself or use one offered by partner companies, such as a toothpaste manufacturer.
• Considered a legal document, the card must be kept for 5 years from the day the patient last visited dentistry and a corresponding entry was made on the card. The document is then archived.
• The contents of medical records should exclude the possibility of breach of confidentiality and illegal access to them, so it is best to keep them under lock and key.

Informed voluntary consent for dental treatment

Dental services are included in the "List of certain types of medical interventions for which citizens give informed voluntary consent when choosing a doctor and a medical organization for receiving 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 testifies that he is voluntarily treated in dentistry, he was explained in detail the need for certain procedures, the plan of which is prescribed in his medical record. The client demonstrates an understanding of possible outcomes, existing risks, and alternative treatment options. He is aware of the possible side 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 in the process.

The document can be signed by the patient himself or by an authorized person (if there is a document confirming 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 (name, date of birth, type of identity document, and so on) in accordance with existing legislation. If the patient is a minor, then the consent to the processing of personal data is signed by the parents or legal representatives.

All materials were provided by the RaTiKa dental clinic (Yekaterinburg). Text: Elizabeth Gertner

OKUD form code ___________

Institution code according to OKPO ______

Medical documentation

Form No. 043/y

Approved by the Ministry of Health of the USSR

04.10.80 No. 1030

name of institution

MEDICAL CARD

dental patient

No. _____________ 19 ... g. ____________

Full Name ________________________________________________________

Gender (M., F.) ______________________ Age ___________________________________

Address _________________________________________________________________________

Profession _____________________________________________________________________

Diagnosis _____________________________________________________________________________

Complaints ________________________________________________________________________

Past and concomitant diseases ______________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Development of the present disease _______________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

For typography!

when creating a document

A5 format

Page 2 f. No. 043/y

Objective examination data, external examination ______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Examination of the oral cavity. Dental condition

Symbols: absent -

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, laboratory data _______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Page 3 f. No. 043/y

date		Surname of the attending physician

Outcomes of treatment (epicrisis) __________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Instructions ___________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Attending physician _______________ Head of department _____________________

Page 4 f. No. 043/y

Treatment _______________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

	History, status, diagnosis, and treatment in dealing with recurrent illnesses	Surname of the attending physician

Page 5 f. No. 043/u

Survey plan	Treatment plan	Consultations

etc. to the bottom of the page