Recommendations for students on filling out a medical record of a dental patient with defects in hard dental tissues at the Department of Orthopedic Dentistry. Algorithm for issuing a "medical record of a dental patient" Correct filling of the card

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:

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

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.

Since the creation of the modern structure of dental care, the medical record of the dental patient has been its basic element. It existed when other documents, without which it is impossible to imagine the work of a modern clinic, (contract, protocol of voluntary informed consent, insurance policy, etc.) were not yet known at all.

At the same time, many dental clinics completely or partially ignore the role of the dental patient's medical record: they either do not use it at all, or modernize, modify, invent their own options. And if the use of various variations on the theme of the medical record of a dental patient can be understood (in many respects, the existing form is already lagging behind the requirements of the time), then the complete absence of a medical record is completely unacceptable.

What is a dental patient's medical record?

The medical record of a dental patient is a document that properly identifies the patient and contains information characterizing the features of the condition and changes in the state of his health, established by the doctor and confirmed by the data of laboratory, instrumental and hardware studies, as well as the stages and features of the treatment.

Registration of a medical card of a dental patient -

The medical record of a dental patient is issued in accordance with the orders of the USSR Ministry of Health No. 1030 dated 04.10.1980 and No. 1338 dated 12.31.1987. At the same time, the Ministries of Health of the USSR and the Russian Federation managed to arrange extreme confusion with the medical record. In 1988, an order of the Ministry of Health of the USSR (No. 750 dated 05.10.1988) was issued, according to which the order of the Ministry of Health No. 1030 became invalid. However, another, newer Ministry of Health, now the Russian Federation, since 1993 began to regularly refer to the provisions of the order of the Ministry of Health of the USSR No. 1030, making appropriate changes and additions to it.

There are no later basic orders or other acts of the Ministry of Health of Russia establishing the form of a medical card. Therefore, although many provisions of Order No. 1030 have become invalid, references periodically appear in new regulatory documents to those parts of the order that relate to the maintenance of medical records. In particular, the requirement remains that all medical institutions (we note, regardless of the form of ownership) are required to keep medical records of the established form. In dentistry, this is Form No. 043 / y "Medical record of a dental patient."

What does a medical card include?

Medical card No. 043 / y contains three main sections.

1) First section- passport part. It includes:

• Card number;
• the date of its issuance;
• surname, name and patronymic of the patient;
• patient's age;
• gender of the patient;
• address (place of registration and place of permanent residence);
• profession;
• initial diagnosis;
• information about past and concomitant diseases;
• information about the development of the present (which became the reason for the primary treatment) disease.

This section may be supplemented by passport data (series, number, date and place of issue) for persons over 14 years of age, and birth certificate data for persons under 14 years of age.

2) Second section- objective research data. He contains:

• external examination data;
• oral examination data and a table of the condition of the teeth, filled out using officially accepted abbreviations (absent - O, root - R, caries - C, pulpitis - P, periodontitis - Pt, filled - P, periodontal disease - A, mobility - I, II, III (degree), crown - K, artificial tooth - I);
• bite description;
• description of the state of the oral mucosa, gums, alveolar processes and palate;
• X-ray and laboratory data.

3) Third section- a common part. It consists of:

• survey plan;
• treatment plan;
• features of treatment;
• records of consultations, consultations;
• clarified formulations of clinical diagnoses, etc.

Some features of the medical card

The material and type of the medical record of the dental patient does not matter much. It can be made in a clinic or printed way and, as a rule, is an A5 notebook. The main requirement is that it be on paper and have records in the form approved by law. The passport part is issued by a medical registrar, clinic administrator or nurse.

All other entries in the medical record are made only by a doctor, legibly, without corrections (a printed (computer) version of making an entry is possible), using only generally accepted abbreviations. The wording of diagnoses, anatomical formations, the names of instruments and medicines are indicated in full, without abbreviations, taking into account the officially used terminology. The entry made is confirmed by the signature and personal seal of the doctor.

In addition to the entries, the following must be entered in the medical record (pasted):

• test results (if any) - originals or copies;
• extracts from other medical institutions where dental care was provided, especially if dental care was provided in other institutions after the patient first applied (began to be observed) in this dental clinic;
• medical opinions, expert opinions, consultations received in connection with the diseases for which the patient is observed in this clinic;
  medical opinions, expert opinions, consultations received in connection with other diseases, the course of which may affect the characteristics of a dental disease;
• information on oncological examinations (on the basis of the order of the Ministry of Health of the Russian Federation "On measures to improve the organization of oncological care for the population of the Russian Federation" No. 270 dated September 12, 1997);
• information on the doses of radiation exposure received by the patient during X-ray examinations (based on the order of the Ministry of Health of the Russian Federation “On the introduction of state statistical monitoring of exposure doses to personnel and the public” No. 466 dated December 31, 1999);
• x-rays of the patient's teeth and maxillofacial area, performed in this dental clinic.

Let's take a closer look at the last point. Of the entire evidence base that is used by the parties when considering consumer claims in court in connection with the quality of the services provided, x-rays are of the greatest importance. Why? For example, let's analyze a controversial situation that occurs most often.

The patient treated his teeth in several clinics and took his x-rays everywhere after the end of the treatment. At the same time, of course, in all clinics there were certain documents confirming the fact of treatment (contracts for the provision of services, entries in the medical record, receipts for payment, checks, etc.). In one of the clinics, during treatment, an instrument broke off in the canal of the tooth. However, the patient did not sue the clinic where the instrument was broken, but the richest of those where he was treated.

At the same time, it is practically impossible to prove the absence of the fault of the clinic indicated in the claim if the clinic cannot present an x-ray taken after the completion of the treatment. That is why the clinic is extremely interested that all the images taken by the patient remain with her. However, there are certain legal difficulties here.

The fact is that radiography is usually included in the price list by clinics as a separate type of service. And on the basis of the Civil Code of the Russian Federation and the Law "On Protection of Consumer Rights", the patient has the right to regard the performed x-ray as a paid service, the material expression (result) of which is an x-ray. Accordingly, the patient acquires the full right to take this picture for himself.

Of course, this situation does not suit the clinic at all. Therefore, the clinic usually uses the following exit options:

1. include in the Contract for the provision of dental services a clause according to which the x-rays performed in the clinic are an integral part of the medical record of the dental patient. In this case, all images taken in the clinic remain its property on the basis of an agreement concluded with the patient.
2. give the patient not the image itself, but its image on paper or other media - for example, a copy from a visiograph, or a printout of a scanned image.

However, all of the above applies to the medical record of the dental patient form No. 043 / y. If the dental clinic uses its own form of medical record, then it can have serious problems during the trial. The fact is that the patient can file a petition for the clinic to provide evidence of a medical record of a dental patient of a statutory form (form No. 043 / y).

In this case, the provision by the dental clinic of a medical card of a different form may be interpreted by the court as a formal basis for recognizing this form as not complying with the requirements of the law, and on this basis the card may not be accepted as written evidence. And this will allow you to ignore all the entries made in the card and give the patient reason to accuse the clinic of improper record keeping.

Since this form of the map is really morally outdated and does not fully reflect both changes in civil legislation and new diagnostic and treatment standards, its certain modernization becomes inevitable. Therefore, in dentistry, as a way out of this situation, an insert sheet to the medical record (information sheet) is used, taking into account the specific features of a particular clinic. It is much worse for the dental clinic if the medical record of the dental patient is not kept at all.

Frequently asked Questions -

1. Who makes entries in the medical record?
   The passport part is filled in by the registrar, administrator or nurse, all other entries are made only by the doctor.
2. How are medical records entered?
   Legibly, using only generally accepted abbreviations, without corrections, handwritten or in printed form, assuring the signature and personal seal of the doctor.
3. What is a medical card for?
   For reasonable protection of the interests of the dental clinic, primarily in court.
4. Can dentistry issue a medical card to a patient?
   Formally yes, actually no.
5. What can be the problems for using the wrong card options?
   An incorrect version of the card may not be recognized by the court as written evidence, and the resulting lack of documentation required by law may result in legal claims.
6. Does the patient have the right to take x-rays?
   Yes, at least copies of photographs on paper or other media.
7. How do dentists modernize the medical record?
   Use the insert in the medical record - information sheet.

The date_______________

Complaints: no, for quickly passing pains when eating sweet, cold food in _______ tooth, he applied for the purpose of sanitation.

Anamnesis: ____ the tooth was not previously treated, it was previously treated for caries, the filling fell out (partially), the cavity was noticed on its own, when examined _____ days (week, month) ago, did not seek help.

Objectively: the configuration of the face is not changed, the skin is clean, regional lymph nodes are not enlarged. The mouth opens freely. The mucous membrane of the oral cavity is pale pink, moist. On the medial, distal, vestibular, oral, chewing surface (s) of ______ tooth, a carious cavity of medium depth, filled (partially filled) with softened pigmented dentin, filling material. Probing is painful along the enamel-dentin border, percussion is painless, the reaction to temperature stimuli is painful, quickly passing. GI=___________.

D.S. : Medium caries _______ tooth. Black class _________.

Treatment: Psychological preparation for treatment. Under anesthesia, without anesthesia, preparation of the carious cavity (removal of the filling), drug treatment with 3.25% sodium hypochlorite solution, washing, drying. Grinding. Polishing.

Filling insulation: Vaseline, Aksil, varnish.

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/u

Objective examination data, external examination ______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Bite ________________________________________________________________________

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

_______________________________________________________________________________

_______________________________________________________________________________

X-ray, laboratory data _______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Page 3 f. No. 043/y

Outcomes of treatment (epicrisis) __________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Instructions ___________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Attending physician _______________ Head of department _____________________

Page 4 f. No. 043/u

Treatment _______________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Page 5 f. No. 043/u

etc. to the bottom of the page