Otitis

Algorithm for preparing a medical record for a dental patient. III

OPTIONS FOR RECORDING THE ILLNESS HISTORY OF PATIENTS WHO ARE SUGGESTED TOOTH EXTRACTION AND OTHER SURGICAL MANIPULATIONS

Exacerbation of chronic periodontitis

Example 1.

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

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

Local changes. There is no change during external examination. The submandibular lymph nodes are slightly enlarged on the left, painless on palpation. The mouth opens freely. In the oral cavity: 27 under a filling, the color is changed, its percussion is painful. In the area of the apex of roots 27, a slight swelling of the mucous membrane of the gums on the vestibular side is detected; palpation of this area is slightly painful. On X-ray 27, the palatal root is sealed to the apex, the buccal roots are filled to 1/2 of their length. At the apex of the anterior buccal root there is a loss of bone tissue with unclear contours.

Diagnosis: “exacerbation of chronic periodontitis of the 27th tooth.”

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

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

B) Under infiltration and palatal anesthesia (anaesthetics, see the entry above, indicate the presence of adrenaline), removal was performed (15, 14, 24, 25). Curettage of the socket(s), the socket(s) became filled with blood clot(s).

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

E) Under infiltration and incisive anesthesia (see anesthetics 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 incisal anesthesia (see anesthetics 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

Example 2.

Complaints of pain in the area of 32, radiating to the ear, pain when biting on 32, a feeling of an “overgrown” tooth. General condition is satisfactory; past diseases: pneumonia, childhood infections.

History of the disease. About a year ago, pain first appeared at 32, and was especially bothersome at night. The patient did not see a doctor; gradually the pain subsided. About 32 days ago the pain reappeared; consulted a doctor.

Local changes. There are no changes upon external examination. The submental lymph nodes are slightly enlarged and 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 and swollen. There are no changes on X-ray 32.

Diagnosis: “acute purulent periodontitis 32".

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

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

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

C) Under bilateral mandibular anesthesia (see anesthetics above), 42, 41, 31, 32 were removed. The hole was curetted; it was compressed and filled with a blood clot.

D) Under infiltration anesthesia (see anesthetics 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

Example 3.

Complaints of swelling of the right cheek, pain in this area, increased body temperature.

Previous and concomitant diseases: duodenal ulcer, colitis.

History of the disease. Five days ago pain appeared at 13; two days later swelling appeared in the gum area, and then in buccal area. The patient did not consult a doctor; he applied a heating pad to his cheek, took warm intraoral soda baths, and took analgia, but the pain grew, the swelling increased, and the patient consulted a doctor.

Local changes. An external examination reveals a violation of the facial configuration due to swelling in the buccal and infraorbital areas on the right. The skin over it is not changed in color, it folds painlessly. The submandibular lymph nodes on the right are enlarged, compacted, and slightly painful on palpation. The mouth opens freely. In the oral cavity: 13 - the crown is destroyed, its percussion is moderately painful, mobility is II – III degree. Pus is released from under the gingival margin. The transitional fold in the area 14, 13, 12 bulges significantly, is painful on palpation, and fluctuation is detected.

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

Example 4.

Complaints of swelling lower lip s and chin, extending to the upper part of the submental 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 undergo treatment; he went to the clinic on the 4th day of the disease.

Past and concomitant diseases: influenza, sore throat, penicillin intolerance.

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

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

^ Record surgical intervention for acute purulent periostitis of the jaws

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

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

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

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

The patient's condition is satisfactory. There is an improvement (or worsening, or no change). The pain in the jaw area has decreased (or increased, remains the same). The swelling of the peri-maxillary tissues has decreased, and 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 furatsilin at a dilution of 1:5000. A rubber strip is inserted into the wound (or the wound is drained with a rubber strip)

Example 5.

Complaints of pain in the area hard palate on the left is pulsating in nature and the presence of swelling on the hard palate. The pain intensifies when touching the swelling with the tongue.

History of the disease. Three days ago, pain appeared in the previously treated 24, pain when biting, and a feeling of an “overgrown 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: stage II hypertension, cardiosclerosis.

Local changes. Upon external examination, the configuration of the face was not changed. Palpation reveals an increase in the submandibular lymph nodes on the left, which are painless. Mouth opening freely. In the oral cavity: on the hard palate on the left, respectively 23 24 there is an opal-shaped bulge with fairly clear boundaries, the mucous membrane above it is sharply hyperemic. At its center there is a fluctuation. 24 - the crown is partially destroyed, there is a deep carious cavity. Percussion of the tooth is painful, tooth mobility is grade I.

Diagnosis: “acute purulent periostitis of the upper jaw on the palatal side to the left (palatal abscess) from the 24th tooth.”

Under palatal and incisal anesthesia (specify the anesthetic and the addition of adrenaline), the abscess of the hard palate was opened with excision of soft tissue to the bone in the form of a triangular flap within the entire infiltrate, and pus was obtained. The wound was drained with a rubber strip. Appointed drug therapy(specify which one).

The patient is incapacitated from _______ to _______., sick leave No. _______ was issued. Show up _________for dressing.

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

All medical record data is filled out by a doctor and confirmed by instrumental, laboratory and hardware research. 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 on dental treatment, consent to the processing of personal data and the dental patient’s medical record.

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

Medical record of a dental patient

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

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

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

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

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

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

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

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

Rules for storing medical records

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

Informed voluntary consent to dental treatment

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

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

Consent to the processing of personal data

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

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

OKUD form code ___________

OKPO institution code ______

Medical documentation

Form No. 043/у

Approved by the USSR Ministry of Health

04.10.80 No. 1030

name of institution

MEDICAL CARD

dental patient

No. _____________ 19... ____________

Last name, first name, patronymic ____________________________________________________________

Gender (M., F.) ______________________ Age ___________________________________

Address _________________________________________________________________________

Profession _____________________________________________________________________

Diagnosis ________________________________________________________________________________

Complaints ______________________________________________________________________________

Previous and concomitant diseases _____________________________________________

_______________________________________________________________________________

Development of the present disease ________________________________________________

_______________________________________________________________________________

For the printing house!

when preparing a document

A5 format

Page 2 f. No. 043/у

Objective research data, external examination ______________________________

_______________________________________________________________________________

Examination of the oral cavity. Dental condition

Legend: none -

0, root - R, Caries - C,

Pulpitis - P, periodontitis - Pt,

sealed - P,

Periodontal disease - A, mobility - I, II

III (degree), crown - K,

art tooth - I

_______________________________________________________________________________

Bite __________________________________________________________________________

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

_______________________________________________________________________________

X-ray and laboratory data ______________________________

_______________________________________________________________________________

Page 3 f. No. 043/у

Date		Last name of the attending physician

Treatment results (epicrisis) ___________________________________________________

_______________________________________________________________________________

Instructions ___________________________________________________________________

_______________________________________________________________________________

Attending physician _______________ Head of department _____________________

Page 4 f. No. 043/у

Treatment _______________________________________________________________________

_______________________________________________________________________________

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

Page 5 f. No. 043/у

Survey plan	Treatment plan	Consultations

etc. to the end of the page

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.

Let me note that this tool may be ineffective if maintaining a dental patient’s medical record 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 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 expert, it is always a huge 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 a medical record as a means of protection, then we can distinguish two equally important blocks: the form of the medical record and its content.

Dental patient medical record form

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

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

Also, sometimes questions arise about the use of electronic medical records, and everyone has three completely different things in mind:

The first option is a situation where you have a 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 and is pasted into the medical record. This is a valid option, the best one today, because the program, as a rule, takes a lot into account and everything is clear.

The second option also uses software, but the dental patient’s medical record is maintained only in electronic form, it is stored in the computer’s memory and is not printed. If a conflict situation arises in court, such a medical record will most likely be considered inadmissible evidence.

The third, ideal option, which is envisaged by the state health care development program until 2020, is the “Electronic Medical History”. 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. Uninterrupted electrical power must be provided with constant access, the protection of personal data and the impossibility of losing information must be proven. It is also necessary that patients and doctors can digitally sign 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. Doctors often use English and Latin terms that are not always clear to the patient, and he must understand everything that is written in his chart. This also applies to abbreviations, of course, there are official, generally accepted abbreviations, but sometimes doctors abbreviate much more than is generally accepted. In this case, you need to make a list of your abbreviations, print it out and paste it into the card so that the client also understands them.

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

You might be interested

Checking a patient's complaint against a dental clinic

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

“Given” is what the patient comes to your clinic with. “Given” means complaints described in detail, always in detail. Record all complaints painful sensations, describe the oral cavity in detail, especially if the patient came from another clinic, because, in the case trial, getting an extract from there will be quite problematic. You immediately need to record the situation with which the patient came. “Given” also refers to x-ray, its mandatory description. If you are doing large-scale work in the clinic on orthopedics, orthodontics, or surgery, it is advisable that you have a radiologist at least a quarter of the time, or part-time. “Given” includes photographs of treatment, that is, photo-logging, which is carried out where it is important aesthetic result, there must be “before” pictures. If there is no fixation of what is given, then it is impossible to evaluate the result.
"What did they do" - detailed description what manipulations were carried out, with what help; The more detail you describe, the more significant the role this record will play in protecting the doctor.
Result. Mandatory photo recording, if the aesthetic aspect is important, mandatory recording of the recommendations that you give to the patient to preserve the result obtained. The recommendation is the most strong thing in defending a medical organization in court. If recommendations were prescribed, and the patient ignored them, then in court all charges against the clinic may be dropped. In order for recommendations to save you, two factors must be taken into account. You must prove that:

you gave recommendations
these recommendations were not implemented.

Therefore, the recommendations must have the client’s signature, and the phrase: “Recommendations have been given” will not help in this situation. The result also includes notifications of required appearances; this is also a point that is taken into account in court. Recommendations can be written down in the medical record each time, or you can develop a single list where all the recommendations regarding the manipulations that you carry out will be collected, and the patient only signs, confirming that he is familiar with them.

Notify patient of required appearances. If the date of appearance and the fact of no-show are recorded, then this also works in favor of the clinic in conflict situations. Also, if the patient does not come to the scheduled appearance, 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 and were interested in his arrival.

The diagnosis must be made according to 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 chart according to both classifications: the generally accepted ICD-10 and the dental one.

Very important point– coordination of the treatment plan and its modification. We are talking about long-term manipulations (orthopedists and orthodontists), where you practically cannot give strict deadlines, 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 patient’s signature, because your patient is also a consumer, and according to the law on consumer protection, you need to agree with him on the type of work, volume, term and price. It is also necessary to specify the warranty periods, as well as the reasons why they were reduced, if this happened.

Storage periods for a dental patient's medical record

According to the new rules, the patient’s medical record must now be stored not for 5 years (Order of the USSR Ministry of Health No. 1030 of October 4, 1980), but for 25 years (Letter of the Ministry of Health of the Russian Federation of December 7, 2015 No. 13-2/1538).

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

Don’t forget, the medical record has actually become part of the contract with the patient. It is necessary to have the patient’s signature on the card, this is confirmation of complaints, medical history, services provided, recommendations, and the need to appear.

Afanasyev V.V., Barer G.M., Ibragimov T.I. Dentistry. Recording and maintaining a medical history: A practical guide. M.: VUNMC Roszdrav, 2006.
Saversky A.V. Patients' rights 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 medical care and management medical documentation. St. Petersburg: CNIT, 2004.

The medical card is mandatory document for each medical institution. It summarizes information about the client’s health, being an integral part of the clinic’s document flow.

Filling it out correctly guarantees the preservation of information about a person’s health, treatment and its results. The dental patient's medical record has important features, so you need to know what it is and how it is filled out.

What is it, what distinguishes it from a regular medical record?

An outpatient card is a standard document that includes basic information about the client, medical history, diagnosis and course of treatment. This is one of the main primary documents in a medical institution, allowing you to systematize information. It also has important legal significance, allowing one to prove the case in controversial situations.

An important feature of a dental medical record and its difference is its highly specialized focus - it reflects the person’s condition.

Legislative framework: understanding the orders

Form 043/у is established by Order of the USSR Ministry of Health No. 1030. By letter dated November 30, 2009, the Ministry of Health and Social Development of the Russian Federation recommended this form for use by dentists. It is uniform for both public dental clinics and commercial ones.

Since form 043/у is approved at the legislative level, it is a reporting document.

Sample form 043/у:

Modifications to form 043/у are undesirable, since in controversial situations, for example, in litigation, the evidence will be taken into account from the outpatient card of the dental patient according to the established template.

If necessary, information tabs are pasted into the card printed according to the established template, which complement the content without changing the form itself.

Content - no encryption

Form 043/у has three parts. The first contains passport information:

number and date;
Full name, date of birth of the patient;
address;
job title;
diagnosis by a dentist;
chronic diseases.

The second part of the medical record specifies the diagnosis and examination details:

examination by a dentist;
features of dental condition;
features of bite;
results laboratory tests and radiographic findings.

The third part contains:

instructions and recommendations;
opinions of other highly specialized specialists.

Templates for some card pages:

Sample Dental Patient Treatment Plan:

This is what the dental examination certificate form looks like:

Filled out by whom and how - no one deviates

Dental card forms exist in electronic form, which can be printed either directly in the clinic or ordered printed from a specialized organization. The outpatient card is filled out by clinic staff.

The passport information in the first part is filled out by the administrator of the dental clinic upon the client’s initial visit, or by the nurse upon initial examination dental patient.

The second and third parts are directly related to the diagnosis and treatment regimen, medical history, therefore only a dentist has the right to fill them out.

As part of process automation, we create electronic services, allowing you to save data in electronic form therapeutic interventions, about dental treatment and reaction to anesthesia, dates of visits and appointments, results of radiographic examinations. Electronic medical dental records the patient can be filled out along with paper medical records. If the dental clinic conducts electronic document management, this does not cancel her obligation to fill out form 043/y on paper.

What information is entered and what is transferred?

After the dentist conducts an examination and the test results appear, information is entered in the “diagnosis” column. The date is indicated.

Requirements for diagnosis: detailed and descriptive in nature regarding the condition of the teeth and oral cavity as a whole.

Describing the disease, the doctor specifies the time of the first signs, the course, the patient’s complaints, what treatment was carried out and with what result.

Diseases can be noted on a special insert, which is a. When the patient returns again, entries must be made in the card diary.

Entries must be made in legible handwriting; blots and corrections are excluded. Filling out can be done either by hand or by typewriting - printed sheets are pasted into the medical record.

The attending physician records the dates of admission, the course of the disease and the effectiveness of the treatment, prescribed medications, and procedures. Common names and abbreviations are used. All relevant information is entered after the patient is admitted.

In addition to the required data, the following information can be entered:

opinions of dentists from other medical institutions;
results and data on the degree of exposure during such examination;
test results.

Now patients have the opportunity to maintain a personal medical record and communicate with their attending physician using the Medkarta24 platform. There is a similar platform for readers from Ukraine.

Where is it stored, where can it hide?

This patient's medical dental record contains personal health data, their safety is guaranteed by law. When a client first contacts dentistry, he signs consent to the storage, recording and processing of personal information and his personal data. Only if there is consent, the storage of such information by the clinic will be considered legal. Providing the patient’s personal data to other persons is possible only if he has given permission to do so, or if there is a court order.

The dental patient's outpatient card is stored in dental clinic 5 years, which are calculated from the last visit of the client. Then it is handed over to the archives.

Letter of the Ministry of Health and Social Development of the Russian Federation dated 04.04.2005 N 734/MZ-14 allows the card to be issued to the patient - but only with the permission of the head doctor of the institution. The refusal may be motivated by the fact that this medical documentation is the property of dentistry, as well as a document of strict accountability.

At the same time, the client has the right to obtain information about his health. He has the right to familiarize himself with his card. Upon request, he can be provided with extracts and copies containing information about the types medical intervention, treatment and examination. In this way, the client will be able to obtain complete information without taking the medical record outside the threshold of the medical institution.

Sample extract from the card:

If a patient arranges a transfer from one clinic to another by compulsory medical insurance policy, there is no need to demand that the patient’s card be issued in person - the clinic receiving the patient will itself request documentation from the clinic that previously served the patient. The transfer of the patient’s hospital card is carried out by the clinic management within three days.

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

GOU DPO KSMA Roszdrav

Approved

Ministry of Health

Republic of Tatarstan

Minister A.Z. Farrakhov

Reviewers:

Doctor of Medical Sciences, Professor R.Z. Urazova

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

Kazan: 2008

Introduction

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

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

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

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

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

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

Case history diagram

General information (Profile details).

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

2. Age, year of birth

4. Place of work

5. Position held

6. Home address

7. Date of visit to the clinic

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

I.Patient's complaints.

1. Main complaints.

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

a) localization of pain;

b) pain is spontaneous or causal;

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

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

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

f) presence or absence of night pain;

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

h) duration painful attacks and light spaces;

i) factors that relieve pain;

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

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

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

2. Additional complaints

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

2.1 Digestive organs.

1. Feeling of dry mouth.

2. The presence of increased salivation.

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

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

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

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

7. Availability unpleasant odor from the mouth.

3. Complaints that determine the general condition

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

II.History of the present disease.

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

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

2. What does the patient associate his illness with?

3. Onset of the disease - acute or gradual.

4. First symptoms.

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

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

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

III.History of the patient's life.

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

1. Place of birth.

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

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

4. Current living conditions.

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

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

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

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

9. Tolerance of drugs. Allergic reactions.

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

Objective examination data

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

I. Inspection.

When examining, pay attention to:

1. General condition (good, satisfactory, moderate severity, heavy, very heavy).

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

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

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

5. Presence or absence of asymmetry.

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

7. Degree of mouth opening.

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

9. Skin and visible mucous membranes:

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

10. Lymph nodes:

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

II. Plan and sequence of oral examination.

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

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

The examination usually begins with the right half of the upper jaw, then examines it left side, lower jaw on the left; finishing inspection at right side in the retromolar region 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 vestibule is considered shallow if its depth is no more than 5 mm, medium - 8-10 mm, deep - more than 10 mm.

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

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

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

III. The most common clinical dental designation systems.

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

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

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

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

01 - upper jaw

02 - lower jaw

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

sextant 03 - upper right rear teeth

sextant 04 - upper canines and incisors

sextant 05 - upper left rear teeth

sextant 06 - lower left rear teeth

sextant 07 – lower canines and incisors

sextant 08 - lower right rear teeth.

V. Notation various types dental lesions.

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

C - caries

P - pulpitis

Pt - periodontitis

R - root

F - fluorosis

G - hypoplasia

Cl - wedge-shaped defect

O - missing tooth

K - artificial crown

I - artificial tooth

VI. Probing.

This procedure is carried out using a dental probe. This allows you to make a judgment about the nature of the enamel and identify defects on it. The probe determines the density of the bottom and walls of the cavity in the hard tissues of the teeth, as well as their pain sensitivity. Sounding makes it possible to judge the depth 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 infiltration on alveolar process or along a transitional fold.

Additional research methods

For staging accurate diagnosis and carrying out differential diagnosis of dental diseases, it is necessary to carry out additional examination methods.

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

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

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

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

staining the entire surface of the tooth - 5 points,

3/4 surface - 4 points,

1/2 surface - 3 points,

1/4 surface - 2 points,

absence of staining - 1 point.

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

1.2. Qualitative assessment:

no staining - 1 point,

weak staining - 2 points,

intense coloring - 3 points.

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

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

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

0—no staining;

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

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

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

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

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

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

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

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

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

By Wed. = K and / n

By Wed - general indicator clean teeth

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

n is the number of teeth being examined

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

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

0 points - no staining

1 point - coloring of any intensity

The Hygiene Performance Index is calculated using the formula:

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

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

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

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

II. Vital staining of hard dental tissues.

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

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

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

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

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

III. Determination of the functional state of enamel.

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

1. TER test.

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

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

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

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

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

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

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

IV. Index of intensity of dental caries damage.

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

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

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

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

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

1st degree - index up to 4 (compensated)

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

V. Thermometric study.

Thermometry determines the reaction of dental tissues to the action of thermal stimuli.

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

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

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

VI. Electroodontometry (EOM).

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

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

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

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

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

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

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

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

VII. Transillumination.

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

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

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

VIII. Luminescent diagnostics.

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

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

IX. X-ray examination.

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

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

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

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

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

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

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

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

1 point - normal apical periodontium,

2 points - bone structural changes indicating pe-

riapecal periodontitis, but not typical for it,

3 points - bone structural changes with some loss

mineral part, characteristic of the apical pe-

rhiodonta,

4 points - clearly visible enlightenment,

5 points - enlightenment with radical spread of co-

nal structural changes.

X.Laboratory research methods.

1. Determination of pH of oral fluid.

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

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

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

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

2. Determination of saliva viscosity.

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

The viscosity of saliva is judged by the formula:

t 1 — saliva viscometry time

t 2 - water viscometry time

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

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

3. Determination of lysozyme activity in saliva.

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

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

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

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

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

Mandatory inserts in the medical record of a dental patient

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

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

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

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

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

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

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

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

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

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

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

Informed voluntary written consentfor medical intervention

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

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

Failure papatient from medical intervention

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

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

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

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