III. standards for treatment and samples of filling out a medical record of a dental patient in the treatment of major dental diseases. Medical record of a dental patient: rules for registration and storage Samples of filling out a dental

A medical record of a dental patient is not just a document, but one of the main means of resolving conflicts with patients for a medical organization, along with a contract and informed consent.

I note that this tool can be ineffective if the maintenance of a medical record of a dental patient is not taken seriously enough. There is an expression that a doctor writes a medical record for the prosecutor, in fact, the doctor writes it exclusively for himself, for his own peace of mind, since the patient’s medical record is, first of all, a kind of support and confidence. After all, if a doctor goes to court, even as a witness or an expert, it is always a colossal stress, so the main task of correctly filling out a medical record is to ensure that the situation does not reach the court.

If we talk about the effectiveness of the medical record as a means of protection, then two equally important blocks can be distinguished: the form of the medical record and its content.

Form of a medical card of a dental patient

New medical documentation forms were approved by order of the Ministry of Health of Russia No. 834n dated December 15, 2014. Prior to this, forms were used for a long time by order No. 1030 of October 4, 1980, which was adopted by the USSR Ministry of Health, since it largely met the necessary requirements. The new order is often illogical, now it contains about 12 forms, but it is not always clear why they were included in the order. For example, there is no general form for a dental patient. But there appeared an orthodontic card of a dental patient, which was developed to a greater extent for scientific activity.

One of the frequently asked questions: is it possible to supplement the form of a medical record of a dental patient? You can add additional information to it, but it is advisable not to remove from there what is there. Whether you will fill everything in completely is another question, but it is better to leave the columns themselves. Otherwise, a competent lawyer will say that the form of the medical record is not approved and cannot be evidence in court, because it does not meet the requirements of the law.

Questions also sometimes arise about the use of electronic health records, while everyone has three completely different things in mind:

The first option is a situation where you have specialized software where you enter patient data into the program, then print out the already completed form. The form is signed by the doctor and the patient, it is pasted into the medical record. This is an acceptable option, the best one today, because, as a rule, a lot is taken into account in the program, and everything is clear.

In the second option, software is also used, but the dental patient's medical record is kept only in electronic form, it is stored in the computer's memory, not printed. In the event of a conflict situation in court, such a medical record will most likely be recognized as inadmissible evidence.

The third, ideal option, which is envisaged by the state program for the development of health care until 2020, is the "Electronic medical record". If you want to keep a medical record only in electronic form, then it must comply with GOST "Electronic Medical History", but this is not so easy to do. An uninterrupted power supply with the possibility of constant access must be provided, the protection of personal data and the impossibility of losing information must be proven. It is also necessary that patients and doctors can put a digital signature on this electronic document. Very rarely all these conditions are met.

The language of the medical record is Russian. If you want to use a foreign word, it is better to replace it with an alternative Russian one. Often doctors use English and Latin terms that are not always clear to the patient, and he must understand everything that is written in his card. This also applies to abbreviations, of course, there are official, generally accepted abbreviations, but sometimes doctors cut much more than the generally accepted one. In this case, you need to make a list of your abbreviations, print it out and paste it on the card so that the client also understands them.

As for the corrections made to the card: the use of a stroke, "scribble", sticking pieces of a medical card - all of the above is unacceptable. A medical record of a dental patient with such corrections cannot be assessed by experts as proper evidence, and as a result, it will be interpreted not in favor of the doctor.

You may be interested

• Checking on a patient's complaint to a dental clinic

Here you should use a simple formula that is easy to remember: Given + What did you do = Result.

1. "Given" is what the patient comes to your clinic with. "Given" - these are complaints described in detail, necessarily in detail. Write down all complaints, pain sensations, describe the oral cavity in detail, especially if the patient came from another clinic, because, in the event of a trial, it will be quite problematic to get an extract from there. Immediately you need to fix the situation with which the patient came. "Dano" also includes an x-ray, its obligatory description. If you are doing large-scale work in orthopedics, orthodontics, surgery in the clinic, it is desirable that you have at least a quarter of the rate, a part-time radiologist. "Dano" includes photographs of treatment, that is, photo-recording, which is carried out where the aesthetic result is important, there must be pictures "before". If there is no fixation of what is given, then it is impossible to evaluate the result.
2. “What they did” - a detailed description of what manipulations were carried out, with what help; the more detailed you describe, the more significant this record will play in protecting the doctor.
3. Result. Mandatory photo recording, if the aesthetic moment matters, mandatory recording of the recommendations that you give to the patient in order to save the result. A recommendation is the most powerful thing in defending a medical organization in court. If the recommendations were prescribed, and the patient ignored them, then all charges can be dropped from the clinic in court. In order for recommendations to save you, two factors must be taken into account. You must prove that:

• you made recommendations
• these recommendations were not implemented.

Therefore, the client's signature must be under the recommendations, and the phrase: “Recommendations have been given” will not save in this situation. The result also includes notifications of the necessary appearances, this is also a moment that is taken into account in court. Recommendations can be written in the medical record every time, or you can develop a single list where all recommendations will be collected regarding the manipulations that you perform, and the patient only puts his signature, confirming that he is familiar with them.

Notify the patient of required appointments. If the date of appearance and the fact of non-appearance are fixed, then this also works in favor of the clinic in conflict situations. Also, if the patient did not come to the appointed turnout, and you know that his situation is difficult, then you should send him 2-3 telegrams (registered letters) to again prove in court that you did everything in your power, were interested in his arrival.

The diagnosis must be made according to the ICD-10. This may not be very convenient for dentists who have their own classification, but it is important for experts. You can write diagnoses in the map according to both classifications: according to the generally accepted ICD-10 and dental.

A very important point is the coordination of the treatment plan and its modification. We are talking about long-term manipulations (orthopedists and orthodontists), where you can hardly name a strict deadline, situations where the price may change, because one of the treatment methods did not work. It is imperative to write down the initial plan, with terms and price, and make all changes, accompanied by the signature of the patient, because your patient is also a consumer, and according to the consumer protection law, the type of work, volume, term and price must be agreed with him. It is also mandatory to prescribe the warranty periods, as well as the reasons why they were reduced, if this happened.

Terms of storage of a medical record of a dental patient

According to the new rules, the patient's medical record must now be kept not for 5 years (Order of the Ministry of Health of the USSR No. 1030 of 04.10.1980), but for 25 years (Letter of the Ministry of Health of the Russian Federation of 07.12.2015 No. 13-2 / 1538).

According to the Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017: the proper completion of a medical record is one of the criteria for the quality of medical care.

Do not forget, the medical card has actually become part of the contract with the patient. It is necessary to have the patient's signature in the card, this is a confirmation of complaints, anamnesis, services rendered, recommendations, the need for appearances.

• Afanasiev V.V., Barer G.M., Ibragimov T.I. Dentistry. Recording and maintaining a medical history: A practical guide. M.: VUNMTs Roszdrav, 2006.
• Saversky A.V. The rights of patients on paper and in life. M.: EKSMO, 2009.
• Salygina E.S. Legal support for the activities of a private medical organization. M.: Statute, 2013.
• Sashko S.Yu., Ballo A.M. Legal assessment of defects in the provision of medical care and maintenance of medical records. St. Petersburg: TsNIT, 2004.

Medical card of a dental patient

Such a document contains all the necessary information about the patient, the condition of his teeth, bite, treatment methods, types of diseases, as well as a medical book. X-ray readings are also entered into the map.

This is a special document of a new type. Each dental clinic must issue such a card for each patient. The administrator fills in the personal data of the client, and the dentist makes the appropriate entries in the card itself.

Form of a medical card of a dental patient

The legislation of the Russian Federation has established a specific form 043y for a dental patient card. All other types of records are recognized as unofficial, without legal force.

Extract from the medical record of a dental patient

To obtain such an extract, you will need to visit a dental clinic, write an application, make a request. Then it will take time to process the document. What if you need an extract urgently? No time to wait? We are ready to help you.

You can buy an extract from a medical card, a medical card of an inpatient from us. We will do it quickly, the document will be authentic, you can present it to any institution.

Buy a medical card of a dental patient

We offer to buy a dental patient card. Such a card will have all degrees of protection, signed by real doctors. It can be presented to any medical institution. If you have this type of card, you will be able to continue the treatment you started earlier.

Filling out a medical card of a dental patient

Only a medical institution providing dental services has the right to fill out such a document. The front side of the card is drawn up by the administrator, all subsequent entries are made by doctors. Each note must be written legibly, confirmed by the signature and seal of the doctor.

Medical card of a dental patient 2015

This year, only cards corresponding to the 043u sample can be officially used. All other options are not legally binding. For each patient, a medical record of a dental patient form 043y must be entered.

New medical card of a dental patient

In life, there are unforeseen situations when a certain document is urgently required. For example, a medical card of a dental patient, sick leave. We offer to make a genuine document for any person. Such a service is provided promptly, the prepared document will be delivered by courier and handed over personally.

Medical card of a dental patient in Moscow

You can order a medical card of a dental patient from us. The application can be submitted by phone, sent by e-mail or come to us. We will independently issue a medical card for a dental patient form 043u. When the document is issued, executed and approved by the current doctors, our administrator will call you back. We organize delivery in Moscow ourselves, you choose any convenient place.

Buy certificate 043u

Such a certificate 043y will be required for a child going to the camp, and he will also need a certificate for the camp (form 079 / y). In order to get it, you and your child will need to visit a dentist. But, is it worth it to hurt the baby?

We offer to buy certificate 043u quite inexpensively. You need to call us to place an order. On the same day, the courier will deliver the document to the place you specify.

Our team consists of experienced dentists who are always ready to help you. Therefore, the medical records drawn up by us, extracts and certificates are real, certified by seals and signatures of acting doctors. You can safely present them to any government agency.

AT THE DEPARTMENT OF ORTHOPEDIC DENTISTRY

Medical card of a dental patient

The main document for recording the work of a dentist of any specialty is a medical record of a dental patient form 043-y, approved by order of the Ministry of Health of the USSR No. 1030 dated 04.10.1980.

A medical card (outpatient card or medical history) is a mandatory document of a medical outpatient appointment that performs the following functions:

• 
  is a plan for a thorough examination of the patient;
• 
  registers the data of the anamnesis, clinical and paraclinical methods of examination of the patient, reflecting the state of the organs and tissues of his oral cavity;
• 
  fixes the plan and stages of treatment, changes that have occurred in the patient's condition;
• 
  makes it possible to compare the results of surveys conducted at different times;
• 
  provides data for scientific research;
• 
  is a legal document that is considered in various conflict situations, including in the courts.

A medical card of the approved form is issued, as a rule, in a typographical way. Currently, clinics practice the use of a formalized computer version of an outpatient card, but with the condition of mandatory duplication on paper.

Medical record (account form 043-y) includes:

• 
  passport part, which is filled in the registry when the patient first visits the clinic;
• 
  medical unit, which is filled directly by the doctor and includes:

- dental status (external examination, examination of the oral cavity);

- data from additional studies (for example, electroodontometry, radiography);

- diagnosis ( basic dental, reflecting morphological and functional disorders of the dental system; related dental; concomitant somatic);

- treatment plan, including, if necessary, preparatory measures (sanation and special) and the actual methods of orthopedic treatment;

- treatment diary.

Writing a case history of patients in an orthopedic dentistry clinic should be based on consistent, sufficiently detailed, competent and accurate filling of all columns of an outpatient dental patient card so that anyone reading it can understand the contents of the records.

Features of writing a medical history of patients

with defects in hard tissues of teeth

1. 
   ^ RATIONALE FOR THE DIAGNOSIS
   1. 
      INTERVIEW

• 
  with defects in the hard tissues of the anterior group of teeth - aesthetic problems caused by congenital or acquired defects in the surface and color of the tissues of the teeth, a change in their shape or position in the dentition, destruction or complete absence of the crown part, etc .;
• 
  with the destruction of the crowns of the chewing group of teeth - a violation of the function of chewing;
• 
  with a significant destruction of a large number of teeth - a change in appearance (changes in the proportions of the face), pain in the temporomandibular joint;
• 
  in some cases - increased sensitivity of the teeth (for example, with increased abrasion of hard tissues of the teeth, with wedge-shaped defects).

Count "Transferred and concomitant diseases" - data are entered on general somatic pathology: diseases of the cardiovascular system, gastrointestinal tract, endocrine pathology, infectious diseases, etc. The listed pathological conditions can affect the choice of materials for the manufacture of prostheses, the timing of the start of prosthetics, the stages of the planned treatment, the choice of anesthetics during the preparation of teeth. So, for anesthesia in patients with pathology of the cardiovascular system, the anesthetic should not contain adrenaline.

Count "Allergological History" the patient is asked if there were any allergic reactions to medications, household chemicals, food products, etc., whether anesthesia was previously used, and whether any complications were noted after it was performed.

To diagnose the pathological condition of the dentoalveolar system, a study should be carried out in the most thorough way. patient's dental status followed by a detailed description of it in the medical record.

In concept "dental status" includes data from an external examination of the patient and an examination of his oral cavity.

When describing the results of an external examination, special attention should be paid to:

• 
  signs of a change in proportions - a decrease in the height of the lower part of the face, which may be due to the significant destruction of a large number of chewing teeth, increased abrasion of hard dental tissues;
• 
  the nature of the movements of the lower jaw;
• 
  the nature of the movements of the heads of the temporomandibular joints (which is determined by palpation).

When describing the results of the examination of the patient's oral cavity, fill in dental Formula, which is a two-digit system in which the quadrants (segments) of the jaws and each tooth of the jaw are numbered alternately (from right to left on the upper jaw and from left to right on the lower jaw). The teeth are numbered from the midline. The first number indicates the quadrant (segment) of the jaw, the second - the corresponding tooth.

^ Example:

P with R ShtZ P K K

18 17 16 15 14 13 12 11 ! 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 ! 31 32 33 34 35 36 37 38

S P P K K

In the dental formula, in accordance with the conventions, all teeth are marked ( ^ P- sealed; FROM- with carious cavities, R- with a significantly or completely destroyed crown part); degree of tooth mobility 1, P, W, 1U), teeth with orthopedic constructions ( To- artificial crowns ShtZ- pin tooth), etc.

Under the dental formula, additional data are recorded regarding the teeth to be restored by orthopedic methods: the degree of destruction of the crown part, the presence of fillings and their condition, changes in color and shape, position in the dentition and relative to the occlusal surface of the dentition, exposure of the neck, stability (or degree of mobility) , results of probing and percussion. Separately, the state of the marginal periodontium is described, in particular, changes in the gingival margin (inflammation, recession), the presence of a gingival pocket, its depth, the ratio of the extra- and intra-alveolar parts of the tooth.

Example:

16 - there is a filling on the chewing surface, the marginal fit is broken, the neck of the tooth is exposed, the tooth is stable, percussion is painless.

14 - on the medial surface there is a small carious cavity, probing the cavity is painless.

13 - there is a complete absence of the crown part of the tooth, the root protrudes above the gum level by 0.5-1.0 mm, the root walls are of sufficient thickness, dense, without pigmentation, the root is stable, percussion is painless, marginal gum without signs of inflammation, tightly covers the neck of the tooth.

11 - artificial metal-plastic crown, plastic lining is changed in color, there is hyperemia of the marginal edge of the gums.

21 - the coronal part is changed in color, the medial angle of the cutting edge is chipped, the tooth is stable, located in the dental arch, percussion is painless.

26, 27, 37, 36 - artificial all-metal crowns in a satisfactory condition, tightly cover the necks of the teeth, marginal gums without signs of inflammation.

31, 32, 41, 42 - dental deposits, slight hyperemia of the gingival margin.

45 - on the occlusal surface, the filling is of satisfactory quality, the marginal fit of the filling is not broken, percussion is painless.

46 - on the occlusal surface there is a large filling, changed in color, when probing, a violation of the marginal fit is determined, a chip of the medial lingual tubercle, the tooth is stable, percussion is painless.

In the graph "Bite" record data on the nature of the relationship of the dentition in the position of central occlusion, the depth of overlap in the anterior section and the identified deformation of the occlusal surface of the dentition.

Example:The bite is orthognathic. The crowns of the upper front teeth overlap the lower teeth by more than 1/3. Violation of the surface of the closure of the dentition due to the extension of the 46th tooth relative to the occlusal surface by 1.5 mm (or ¼ of the crown height). There is hypertrophy of the alveolar process in area 46, exposure of the neck of the tooth.

In the column " Data from additional research methods » the results of x-ray examinations are recorded with a detailed description of x-rays of each tooth subject to orthopedic treatment. When “reading” x-rays, the condition of the tooth shadow is assessed and described according to the following scheme:

• 
  the state of the crown - the presence of a carious cavity, fillings, the ratio of the bottom of the carious cavity to the tooth cavity;
• 
  characteristics of the tooth cavity - the presence of a shadow of filling material, instruments, denticles;
• 
  the state of the roots: quantity, shape, size, contours;
• 
  characteristics of root canals: width, direction, degree and quality of filling;
• 
  assessment of the periodontal gap: uniformity, width;
• 
  the state of the compact plate of the hole: preserved, destroyed, thinned, thickened;
• 
  the state of the periapical tissues, analysis of the pathological shadow, determination of its localization, shape, size and nature of the contour;
• 
  assessment of the surrounding tissues: the state of the interdental septa - height, the state of the end compact plate.

^ Example:

On intraoral x-rays of satisfactory quality:

16 - a change in the position of the tooth relative to the adjacent ones is determined (advancement by 1.5 mm in relation to the occlusal surface), in the crown part of the tooth - an intense shadow of the filling material, close to the tooth cavity, the marginal fit of the filling is broken, atrophy of the interdental septa up to 1/3 of the length roots

13 - the absence of the coronal part, in the root canal, throughout the entire length of the canal to the root apex, there is a uniform intense shadow of the filling material. The periodontal gap is not widened, there are no changes in the periapical tissues.

11 – in the region of the coronal part, an intense shadow of the metal frame of the artificial crown is projected, in the root canal up to ½ of its length, an intense shadow of the metal wire pin is traced. In the apical third of the root canal, the shadow of the filling material is not determined. Uniform expansion of the periodontal gap. In the region of the root apex, there is a focus of rarefaction of bone tissue with fuzzy contours in the form of "tongues of flame".

21 – a chip of the medial angle of the cutting edge of the coronal part, in the root canal there is an intense shadow of the filling material with filling defects. No changes were found in the periapical tissues.

46 - in the area of ​​the tooth crown, the shadow of the filling material is close to the cavity of the tooth, the marginal fit of the filling is broken, the root canals are free from the filling material. There are no changes in the periapical tissues.

32, 31, 41, 42 – pathology of hard tissues was not revealed, interdental septa are reduced to 1/3 of the length of the roots, there is a lack of end compact plates, the tops have a "scalloped" appearance.

The same column describes the data of electroodontodiagnostics and other examination methods (for example, the results of tomography of the temporomandibular joints in patients with signs of a decreasing bite).

Based on the data of the clinical examination and the results of additional research methods, a diagnosis . Accordingly, graph "diagnosis" in the medical record is filled out only after a complete examination of the patient.

When making a diagnosis, it is necessary to highlight:

• 
  underlying disease of the dentition and complication of the underlying disease;
• 
  concomitant dental diseases;
• 
  common comorbidities.

The main diagnosis should be detailed, descriptive and comply with the international classification of nosological forms of dental diseases based on the ICD -10 C.

When formulating the main diagnosis, first of all, morphological changes in the dentition are distinguished, indicating the etiological factor (for example, partial defect of the crown part of the 46th tooth of carious origin).

In some cases, the underlying disease (in the example partial defect of the crown part of the 46 tooth) may be accompanied by complications, in particular, in the form of deformations of the occlusal surface of the dentition (change in the position of the 16th tooth - dentoalveolar elongation of the 1st degree of the P-a form in the region of the 16th tooth), which should also be reflected in the diagnosis.

In the given example morphological part of the main diagnosis is formulated as follows:

“Complete defect of the crown part of the 13th tooth of carious origin (IROPZ more than 0.8). Functional and aesthetic insufficiency of the artificial crown of the 12th tooth. Partial defect with a change in the color of hard tissues of the 21st tooth of traumatic origin Partial defect of the crown part of the 46th tooth of carious origin, complicated by deformation of the occlusal surface of the dentition of the upper jaw - dentoalveolar lengthening of the 1st degree of the P-a form in the area of ​​the 16th tooth.

The second component of the main diagnosis is functional part, characterizing dysfunctions, movements of the lower jaw. For example, "Aesthetic insufficiency of the dentition of the upper jaw", « Functional insufficiency of the dentition of the lower jaw», "Blocking movements of the lower jaw."

In the above example, the full wording main diagnosis as follows:

“Complete defect of the crown part of the 13th tooth of carious origin (IROPZ more than 0.8). Functional and aesthetic insufficiency of the artificial crown of the 12th tooth. Partial defect with a change in the color of hard tissues of the 21st tooth of traumatic origin Partial defect of the crown part of the 46th tooth of carious origin, complicated by deformation of the occlusal surface of the dentition of the upper jaw - - dentoalveolar elongation of the 1st degree of the U-shape in the area of ​​the 16th tooth. Functional and aesthetic insufficiency of the dentition, blocking of the movements of the lower jaw in the anterior occlusion.

AT concomitant dental diagnosis all identified dental pathology is taken out, which will be treated by dentists, dental surgeons, orthodontists (for example, caries, chronic periodontitis, gingivitis, periodontitis, diseases of the oral mucosa, etc.).

Example: « ^ Deep incisal overlap. Chronic localized catarrhal gingivitis in the area of ​​teeth 11, 32, 31, 41, 42. Dental caries 14, 47.

AT concomitant somatic diagnosis there are somatic diseases of the cardiovascular, endocrine, nervous systems, respiratory organs, gastrointestinal tract, etc.

Depending on the formulation of the diagnosis, treatment plan , which, in addition to the actual orthopedic treatment of a defect in the hard tissues of the tooth, may include preliminary preparation of the oral cavity for prosthetics. Preparation of the oral cavity for orthopedic treatment includes general(rehabilitation) and special measures (therapeutic, surgical, orthopedic, orthodontic).

Sanitation measures are carried out if the concomitant dental diagnosis indicates the presence of teeth to be treated (caries, chronic periodontitis), diseases of periodontal tissues (dental deposits, gingivitis, periodontitis in the acute stage), diseases of the oral mucosa, etc.

Example: “The patient is referred for oral cavity sanitation before prosthetics: treatment of teeth 14, 17, removal of dental deposits, treatment of gingivitis. Professional oral hygiene recommended.

Special preparation of teeth is carried out according to prosthetic indications and is necessary for more effective orthopedic treatment and to exclude the possibility of complications after treatment.

Before orthopedic treatment of defects in hard tissues of teeth, more often than others, special therapeutic measures preparation of teeth, among which it should be noted:

• 
  root canal refilling;
• 
  depulpation of teeth planned for orthopedic construction (for example, if radical preparation of teeth with a wide cavity is necessary, with inclinations or vertical movement of teeth);
• 
  preparation of root canals for pin structures (unsealing of root canals).

The ultimate goal of orthopedic treatment of hard tissue defects is to restore:

• 
  anatomical shape of the tooth crown;
• 
  unity of the dentition;
• 
  lost functions and aesthetics.

In this regard, in the column "Treatment Plan" the design of dentures should be indicated, with the help of which the goal of orthopedic treatment will be realized.

^ Example:

"Restore the anatomical shape of the coronal part

tooth 16 – cast all-metal crown;

teeth 13, 11 – ceramic-metal crowns on cast stump

pin tabs;

tooth 21 – ceramic-metal crown;

tooth 46 – cast all-metal crown on a cast stump pin tab.

If it is necessary to carry out special preparation of the tooth for prosthetics, the planned activities should also be detailed in the column "Treatment plan".

Example:

1. 
   In order to eliminate the deformation of the occlusal surface of the dentition of the upper jaw, it is recommended to depulp the 16th tooth, followed by its grinding (shortening) and restoring its shape with a cast all-metal crown.
2. 
   Restore the anatomical shape of the crown of the 13th tooth with a cast stump pin tab and a ceramic-metal crown with preliminary preparation of the root canal for a cast stump pin tab (by 2/3 of the length unsealing).
3. 
   Restore the anatomical shape of the crown part of the 11th tooth with a cast stump pin tab and a ceramic-metal crown with a preliminary revision, refilling and preparation of the root canal for a cast stump pin tab.
4. 
   To restore the anatomical shape of the crown part of the 21st tooth with a metal-ceramic crown with a preliminary refilling of the root canal using a fiberglass pin.
5. 
   To restore the anatomical shape of the crown of the 46th tooth with a cast stump pin tab and a cast all-metal crown with preliminary depulpation of the tooth and preparation of channels for a cast stump pin tab.

The patient should be informed by the doctor about all possible options for dental prosthetics and the most optimal method of treatment in this clinical situation, about treatment planning (including the need to prepare the oral cavity for prosthetics for orthopedic indications). An appropriate entry should be made in the medical history (preferably by the patient himself and with his signature) of the following wording: “ I am familiar with the options for prosthetics, I agree with the plan for prosthetics (including the plan for preparing for prosthetics).

In chapter "A diary » describes the clinical stages of orthopedic treatment, indicating the date of admission of the patient and the date of the next appointment. We give examples of filling "Diary" depending on the design of the denture in the orthopedic treatment of defects in the hard tissues of the teeth.

The final section of the medical history of the dental patient "Epicrisis" filled in according to a certain scheme:

Patient (full name) 27.02.09 applied to the clinic of orthopedic dentistry with complaints about _______________________________________.

Based on the examination data, the following diagnosis was made: _________________________________________________________________.

Orthopedic treatment performed _____________________________

____________________________________________________________

The anatomical shape of the crowns of the teeth, the integrity of the dentition of the upper jaw, the lost functions and the aesthetic norm were restored.

The medical history is completed by the signature of the doctor and, preferably, the head of the department.

Card Design Standards (Moscow)

1).Medium caries:

Complaints: short-term pain from cold, sweet taste.....(tooth formula)

Objectively: on ... .. (name) surface ..... (tooth formula) carious

cavity ….. of Black class, filled with softened dentin. Probing is painful along the dentin-enamel border. Short-term pain from thermal stimuli. Percussion is negative.

Treatment: under topical anesthesia (....................... (name)) and

infiltration (conduction) anesthesia (…… (name)) formed

and medically treated cavity. ….(description of conducted

manipulations - seal (number of surfaces). restoration, tab, etc., with the name of the material and color indication)

2).Deep caries:

Complaints: the presence of a carious cavity, ingestion of food, short-term pain from cold in..... (tooth formula).

Objectively: on .... (name) surface ... (tooth formula) there is a carious cavity, ..... according to Black, made with softened dentin. Probing is slightly painful along the entire bottom of the carious cavity. Short-term pain from thermal stimuli. Percussion is negative.

Treatment: Under topical anesthesia (…. (name)) and

Infiltration (conduction) anesthesia (….. (name)) formed

and medically treated cavity. Therapeutic pad .. (name).

Insulating pad …. (title). (description of the manipulations performed - filling, restoration, inlay, etc., with the name of the material and an indication of the color). grinding,

polishing.

3). Exacerbation of chronic pulpitis.

Complaints: Pulsating, prolonged pain, aggravated by temperature stimuli in ... (tooth formula). Night pains.

Objectively: on .... (name) of the surface ... (tooth formula) a carious cavity filled with softened dentin, filling remnants, food remnants. Probing is sharply painful at one point. When probing, the pulp bleeds. From temperature stimuli sharp, trace pain. Percussion is negative.

Treatment: Under application anesthesia .... (name) and

infiltration (conduction) anesthesia ... .. (name) the tooth cavity is opened. Amputation, extirpation. Root canals are mechanically and medically processed. Length (mm).... ISO..... Sealed (description of materials and technology)

Second visit: No complaints

Treatment: ... .(description of manipulations, pin, gasket, filling, restoration, tab indicating materials and colors)

4). Chronic fibrous pulpitis.

Complaints: the presence of a carious cavity, periodic spontaneous pain in .. (tooth formula).

Objectively: On ... (name) surface .... (tooth formula) there is a deep carious cavity communicating with the tooth cavity. Probing is slightly painful. The pulp bleeds on probing. Percussion is negative.

Treatment: Under application anesthesia ... (name) and infiltration (conduction) anesthesia ... (name), the tooth cavity is opened. Amputation, extirpation. Root canals are mechanically and medically processed. Length (mm).... ISO..... Sealed .... (description of materials and technology).

RVG control: the root canal is obturated uniformly tightly throughout its entire length to the physiological opening. Temporary bandage.

Second visit:

There are no complaints.

Objectively: the temporary dressing is preserved. Percussion is negative.

Treatment: ... (Description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and colors)

5). Chronic gangrenous pulpitis.

Complaints: On pain from hot, the presence of a carious cavity in .... (tooth formula)

Objectively: on ... (name) surface .... (tooth formula) deep carious

a cavity filled with gray content communicating with the tooth cavity.

Probing in root canals is painful.

Treatment: Under application anesthesia ... (name) and infiltration (conduction) anesthesia .... (name) the tooth cavity is opened. Amputation, extirpation. Root canals are mechanically and medically processed. Length (mm).... ISO..... sealed..

.(description of materials and technology).

RVG control: the root canal is obturated uniformly tightly throughout its entire length to the physiological opening. Temporary bandage.

Second visit:

No complaints

Objectively: Temporary bandage is saved. Percussion is negative. Treatment:... (description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and colors)

6). Chronic hypertrophic pulpitis.

Complaints: Mild pain from mechanical stimuli, bleeding from

...(tooth formula).

Objectively: On the (name) surface....(tooth formula) there is a deep carious cavity filled with granulation tissue. When probing, the pulp is slightly painful, bleeds.

Treatment: Under application anesthesia (name) and

infiltration (conduction) anesthesia (name) opened the cavity of the tooth. Amputation, extirpation. Root canals are mechanically and medically processed. Length (mm).... ISO..... sealed (description of materials and technology).

RVG control: The root canal is obturated uniformly tightly throughout its entire length to the physiological opening. Temporary bandage.

Second visit:

no complaints

Objectively: Temporary bandage is saved. Percussion is negative. Treatment: .(description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and colors)

7). Exacerbation of chronic periodontitis.

Complaints of constant pain, aggravated by biting, feeling of a "growing tooth".

Objectively: on the (name) surface .... (tooth formula) there is a deep carious cavity communicating with the tooth cavity. Probing is painless. Percussion is sharply positive.

Infiltration (conduction) anesthesia (name) opened the cavity of the tooth. Evacuation of contents from the root canal. Root canals are mechanically and medically processed. Length (mm).... ISO.... Temporary

Second visit:

There are no complaints.

Objectively: Temporary bandage is saved. Percussion is negative.

Treatment: Under application anesthesia (Name) and infiltration (conduction) anesthesia (Name), removal of the Temporary dressing. Medical treatment of root canals. Root canals are sealed (description of materials and technology).

RVG control. The root canal is obturated uniformly tightly throughout its entire length to the physiological opening. Temporary bandage.

Third visit:

No complaints

Objectively: Temporary dressing is preserved. Percussion is negative.

Treatment: (description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and colors)

8). Chronic fibrous periodontitis.

Complaints: about the presence of a carious cavity in .... (tooth formula) ingestion of food.

Objectively: on the (name) surface....(tooth formula), there is a deep carious cavity communicating with the tooth cavity. Probing is painless. Percussion is negative. There is no pain from thermal stimuli.

RVG: expansion of the periodontal gap.

Treatment: Under topical anesthesia (Name) and

infiltration (conduction) anesthesia (name) opened the cavity of the tooth. Evacuation of contents from the root canal. Root canals are mechanically and medically processed. Length (mm).... ISO.... Temporary dressing.

Second visit.

no complaints.

Objectively: Temporary bandage is saved. Percussion is negative.

Treatment: Under topical anesthesia (name) and

infiltration (conduction) anesthesia (name) removal of a temporary bandage. Medical treatment of root canals. root

the channels are sealed (description of materials and technology). RVG control. The root canal is obturated uniformly tightly throughout its entire length to the physiological opening. Temporary bandage.

Third visit:

no complaints

Objectively: Temporary bandage is saved. Percussion is negative. Treatment: (description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and colors)

9). Chronic granulating periodontitis.

complaints: For the presence of a carious cavity in .... (tooth formula), ingestion of food

Objectively: on the (Name) surface (tooth formula), there is a deep carious cavity communicating with the tooth cavity. Probing is painless. Percussion is negative. There is no pain from thermal stimuli.

RVG: expansion of the periodontal fissure, in the region of the apex (which root) there is a focus of destruction with fuzzy contours.

Treatment: Under application anesthesia (name) and infiltration (conduction) anesthesia (name), the tooth cavity is opened. Evacuation of contents from the root canal. Root canals are mechanically and medically treated. Length (scrap).... ISO.... Temporary

Second visit:

no complaints.

Objectively: Temporary bandage is saved. Percussion is negative. Treatment: Under application anesthesia (name) and infiltration (conduction) anesthesia (name) Removal of temporary dressing. Medical treatment of root canals. Root canals are sealed...........(description of materials and technology)

RVG-control: the root canal is obturated uniformly tightly throughout its entire length to the physiological opening, Temporary dressing.

Third visit:

no complaints

Objectively: Temporary bandage is saved. Percussion is negative. Treatment: .. (description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and colors)

10). Chronic granulomatous periodontitis.

Complaints: For the presence of a carious cavity in .... (tooth formula) ingestion of food.

Objectively: on the (name) surface ... (tooth formula), deep carious

cavity communicating with the cavity of the tooth. Probing is painless. Percussion is negative. There is no pain from temperature irritants.

RVG: Expansion of the periodontal gap, in the region of the apex .... (which

root) the focus of destruction with clear contours with a diameter .. (mm)

Treatment: Under application anesthesia ...... (name) and infiltration (conduction) .... (name) the tooth cavity is opened. Evacuation of contents from the root canal. Root canals are mechanically and medically processed. Length (mm).... ISO.temporary bandage.

Second visit:

no complaints.

Objectively: Temporary bandage is saved. Percussion is negative.

Treatment: Under topical anesthesia (name) and

infiltration (conduction) anesthesia (name) removal of the Temporary dressing. Medical treatment of root canals. root

channels are sealed (description of materials and technology).

RVG control. The root canal is obturated uniformly tightly throughout its entire length to the physiological opening, Temporary dressing.

Third visit:

no complaints

Objectively: Temporary bandage is saved. Percy is negative. Treatment: ..... (description of manipulations: pin, gasket, filling, restoration, tab indicating materials and colors)

Medium caries

complaints : for the presence of a carious cavity in the area …………… quickly passing pain from chemical irritants.

Sf/ loc . : in the area of ​​…………… a carious cavity of medium depth with softened pigmented dentin, probing of the enamel-dentin border is painful.

deep caries

complaints :: for the presence of a carious cavity in the area ……………, pain from chemical and thermal irritants, which quickly disappear after the removal of the stimulus.

Sf/1os.: in the area of ​​…………… a deep carious cavity with softened pigmented dentin, probing is painful in the area of ​​the bottom of the carious cavity, the reaction to thermal stimulation is positive, quickly passing.

Chronic pulpitis

complaints : for the presence of a carious cavity in the area of ​​……………, pain from thermal stimuli and when food enters the carious cavity.

Sf/1oc.: In the area of ​​…………… deep carious cavity filled with softened pigmented dentin, probing is painful in the area of ​​the bottom of the carious cavity. Probing revealed an open pulp horn. The reaction to thermal stimuli is positive.

Exacerbation of chronic pulpitis

complaints : for spontaneous paroxysmal, nocturnal pains with irradiation to the area ……………. From the anamnesis: previously there were spontaneous pains.

Sf/1os.: .: In the area …………… deep carious cavity communicating with the cavity of the tooth. probing is sharply painful. The reaction to thermal stimuli is positive, the color of the tooth is not changed.

Chronic fibrous periodontitis is noted

complaints : for the presence of a deep carious cavity in the area…………… From the anamnesis: occasionally it is characterized by slight pain when biting.

Sf/1os.: In the area…………… deep carious cavity communicating with the cavity of the tooth. probing the entrance to the cavity is painless, percussion is painless. the tooth is discolored. On Rg: expansion of the periodontal gap in the region of the root apex.

Chronic granulomatous periodontitis

complaints : for the presence of a deep carious cavity in the area …………… Changing the color of the tooth. From the anamnesis: occasionally there is sensitivity in the jaw and slight pain when biting.

Sf/1os.: In the area: …………… deep carious cavity communicating with the tooth cavity. Probing the entrance to the cavity 6 painless. On palpation on the gum c

The vesti6ular surface is marked with painful swelling. percussion lightly

painful. On Rg: in the region of the root apex, there are clearly defined rarefaction of the bone tissue of a rounded shape with a size of …….

Chronic granulating periodontitis

complaints : for the presence of a deep carious cavity in the area of ​​……………. In the anamnesis, there is occasionally pain when biting, periodic formation of a fistula in the area of……..

Sf/1os.: In the area ……………deep carious cavity communicating with the cavity of the tooth. The tooth is discolored. Probing is painless. Percussion is slightly painful. On the mucous membrane in the area………… there is a fistulous tract with purulent compartments. On Rg: in the region of the root apex there is a focus of bone tissue destruction with corroded contours.

Exacerbation of chronic periodontitis

complaints : on pain of a aching nature in the area …………… Sharp pain when biting on a tooth.

Sf/1os.: .: In the area …………… deep carious cavity communicating with the cavity of the tooth. probing is painless. Percussion is sharply painful. Mucosa in

area…………… hyperemia, slightly edematous. Rg according to the shape.

OPTIONS FOR RECORDING THE HISTORY OF THE DISEASE OF PATIENTS WHO ARE INDICATED FOR TOOTH EXTRACTION AND OTHER SURGICAL MANIPULATIONS

^

Exacerbation of chronic periodontitis

Complaints of pain in the region of the upper jaw on the left, it hurts at 27 when biting.

History of the disease. 27 previously treated, periodically disturbed. Two days ago, 27 fell ill again, there was pain in the region of the upper jaw on the left, pain when biting on 27 increases. History of influenza.

local changes. On external examination, there is no change. Submandibular lymph nodes are slightly enlarged on the left, painless on palpation. The mouth opens freely. In the oral cavity: under a filling, changed in color, its percussion is painful. In the area of ​​the tops of the roots 27, a slight swelling of the gingival mucosa is determined from the vestibular side, palpation of this area is slightly painful. On radiograph 27, the palatine root was sealed up to the apex, the buccal roots - 1/2 of their length. At the apex of the anterior buccal root there is a rarefaction of bone tissue with fuzzy contours.

Diagnosis: "exacerbation of chronic periodontitis 27 tooth".

A) Under tuberal and palatine anesthesia with 2% novocaine solution - 5 mm or 1% trimecanne solution - 5 mm plus 0.1% adrenaline hydrochloride - 2 drops (or without it) extraction was performed (specify the tooth), curettage of the hole ; hole filled with blood clot.

B) Under infiltration and palatine anesthesia (anesthetics, see entry above, indicate the presence of adrenaline), removal was performed (18, 17, 16, 26, 27, 28), curettage of the hole; hole filled with blood clot.

C) Under infiltration and palatine anesthesia (anesthetics, see entry above, indicate the presence of adrenaline), removal was performed (15, 14, 24, 25). Curettage of the hole (holes), the hole (s) filled (were) with a blood clot (s).

D) Under infraorbital and palatine anesthesia (anesthetics see above, indicate the presence of adrenaline) ( 15, 14, 24, 25).

E) Under infiltration and incisive anesthesia (anesthetics see above, indicate the presence of adrenaline) removal was performed (13, 12, 11, 21, 22, 23) . Curettage of the hole, it is compressed and filled with a blood clot.

E) Under infraorbital and incisive anesthesia (anesthetics see above, indicate the presence of adrenaline) removal was performed (13, 12, 11, 21, 22, 23). Curettage of the hole, it is compressed and filled with a blood clot.
^

Acute purulent periodontitis

Complaints of pain in the area of ​​32, radiating to the ear, pain when biting on 32, a feeling of a "grown" tooth. The general condition is satisfactory; past illnesses: pneumonia, childhood infections.

History of the disease. About a year ago, for the first time, pain appeared at 32, it was especially disturbing at night. The patient did not go to the doctor; gradually the pain subsided. 32 days ago, pain reappeared; went to the doctor.

local changes. On external examination, there are no changes. The submental lymph nodes are slightly enlarged, painless on palpation. The mouth opens freely. In the oral cavity 32 - there is a deep carious cavity communicating with the tooth cavity, it is mobile, percussion is painful. The mucous membrane of the gums in area 32 is slightly hyperemic, edematous. There are no changes on the radiograph 32.

Diagnosis: "acute purulent periodontitis 32".

A) Under mandibular and infiltration anesthesia (anesthetics, see above, indicate the presence of adrenaline), an extraction was performed (indicate a tooth) 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38; curettage of the holes, they are compressed and filled with blood clots.

B) Under torusal anesthesia (anesthetics see above, indicate the presence of adrenaline), 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38 were removed.

Curettage of the hole, it is compressed and filled with a blood clot.

C) Under bilateral mandibular anesthesia (anesthetics see above), removal of 42, 41, 31, 32 was performed. Curettage of the hole, it was compressed and filled with a blood clot.

D) Under infiltration anesthesia (anesthetics, see above, indicate the presence of adrenaline), 43, 42, 41, 31, 32, 33 were removed. Curettage of the hole, it was compressed and filled with a blood clot.

^

Acute purulent periostitis

Complaints of swelling of the cheek on the right, pain in this area, fever.

Past and concomitant diseases: duodenal ulcer, colitis.

History of the disease. Five days ago there was pain at 13; Two days later, a swelling appeared in the gum area, and then in the buccal area. The patient did not go to the doctor, applied a heating pad to his cheek, did warm intraoral soda baths, took analgesics, but the pain grew, the swelling increased, and the patient went to the doctor.

local changes. During external examination, a violation of the configuration of the face is determined due to swelling in the buccal and infraorbital regions on the right. The skin above it is not changed in color, painlessly gathers into a fold. The submandibular lymph nodes on the right are enlarged, compacted, slightly painful on palpation. The mouth opens freely. In the oral cavity: 13 - the crown is destroyed, its percussion is moderately painful, mobility II - III degree. Pus is released from under the gingival margin. The transitional fold in the area of ​​14, 13, 12 swells significantly, is painful on palpation, fluctuation is determined.

Diagnosis: "acute purulent periostitis of the upper jaw on the right in the area of ​​14, 13, 12 teeth"

Example 4

Complaints of swelling of the lower lip and chin, extending to the upper part of the chin area; sharp pains in the anterior part of the lower jaw, general weakness, lack of appetite; body temperature 37.6 ºС.

History of the disease. After hypothermia a week ago, spontaneous pain appeared in the previously treated 41, pain when biting. On the third day from the onset of the disease, the pain in the tooth decreased significantly, but swelling of the soft tissues of the lower lip appeared, which gradually increased. The patient did not carry out treatment, he turned to the clinic on the 4th day of the disease.

Past and concomitant diseases: influenza, tonsillitis, intolerance to penicillin.

local changes. During external examination, swelling of the lower lip and chin is determined, its soft tissues are not changed in color, they fold freely. The submental lymph nodes are slightly enlarged, slightly painful on palpation. Opening the mouth is not difficult. In the oral cavity: the transitional fold in the region of 42, 41, 31, 32, 33 is smoothed, its mucous membrane is edematous and hyperemic. On palpation, a painful infiltrate in this area and a positive symptom of fluctuation are determined. Crown 41 is partially destroyed, its percussion is slightly painful, I degree mobility. Percussion 42, 41, 31, 32, 33 painless.

Diagnosis: "acute purulent periostitis of the lower jaw in the area of ​​42, 41, 31, 32".

^ Record of surgical intervention for acute purulent periostitis of the jaws

Under infiltration (or conduction - in this case, specify which one) anesthesia (anesthetic see above, indicate the presence of adrenaline), an incision was made along the transitional fold in the area

18 17 16 15 14 13 12 11|21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41| 31 32 33 34 35 36 37 38

(indicate within which teeth) 3 cm (2 cm) long to the bone. Got pus. The wound was drained with a rubber strip. Assigned (indicate the medications prescribed to the patient, their dosage).

The patient is disabled from _______ to _________, sick leave No. ______ issued. Appearance ______ for dressing.

^

Diary entry after opening a subperiosteal abscess in acute purulent periostitis of the jaw

The patient's condition is satisfactory. Improvement (or deterioration, or no change) is noted. Pain in the jaw area has decreased (or increased, remains the same). The swelling of the maxillary tissues has decreased, a small amount of pus is released from the wound in the oral cavity. The wound along the transitional fold of the jaw was washed with a 3% solution of hydrogen peroxide and a solution of furacilin at a dilution of 1:5000. A rubber band has been inserted into the wound (or the wound has been drained with a rubber band)

Example 5

Complaints of pain in the hard palate on the left of a pulsating character and the presence of swelling in the hard palate. The pain is aggravated by touching the swelling with the tongue.

History of the disease. Three days ago, there was pain in the previously treated 24, pain when biting, feeling of a “grown tooth”. Then the pain in the tooth decreased, but a painful swelling appeared on the hard palate, which gradually increased in size.

Past and concomitant diseases: hypertension II stage, cardiosclerosis.

local changes. On external examination, the configuration of the face was not changed. On palpation, an increase in the submandibular lymph nodes on the left is determined, which are painless. Mouth opening freely. In the oral cavity: on the hard palate on the left, respectively 23 24 there is a disgraced bulging with fairly clear boundaries, the mucous membrane over it is sharply hyperemic. Fluctuation is determined in its center. 24 - the crown is partially destroyed, a deep carious cavity. Percussion of the tooth is painful, tooth mobility I degree.

Diagnosis: "acute purulent periostitis of the upper jaw on the palatine side on the left (palatine abscess) from the 24th tooth."

Under palatine and incisive anesthesia (specify the anesthetic and the addition of adrenaline), an abscess of the hard palate was opened with excision of soft tissues down to the bone in the form of a triangular flap within the entire infiltrate, pus was obtained. The wound was drained with a rubber strip. Drug therapy was prescribed (specify which one).

The patient is disabled from _______ to _______., A sick leave sheet No. _______ was issued. Appearance _________ for dressing.