Facultatea de Medicina Dentara BucurestiDisciplina Protetica Fixa si Ocluzologie
Medic coordonator proiect Prof. Univ. Dr. Alexandru Petre
Nr. fisa_______Data completarii ______________Medic Dr. ____________________________
FISA CLINICA ATM
Nume si prenume ______________________________________________________________
Data nasterii ______________Telefon/mail_________________________________________
1. Motivele prezentarii:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Data aparitiei primelor simptome___________________________________________________
2. Antecedente heterocolaterale___________________________________________________
3. Antecedente personale:
[ ] accidente [ ] fracturi [ ] incidente sportive_______________________________________
[ ] aparat ortodontic in antecedente_________________________________________________
[ ] lucrari stomatologice in ultimii ani/extractii molari de minte___________________________
4. Stil de viata:
[ ] dieta __________________________ [ ] seminte, preferinta parte masticatie ____________
[ ] ceai [ ] cafea [ ] calculator (m.m. de 8h / zi) [ ] exercitii fizice
[ ] tulburari de somn, preferinta parte de dormit__________________ [ ] sforait [ ] apnee de
somn tratament : [ ]CPAP [ ]gutiera [ ]chirurgie ORL
[ ] deglutitie atipica [ ] bruxism [ ] articulatie blocata______________ [ ] zgomote in ureche
[ ] durere in alte articulatii [ ] greata [ ] varsaturi [ ] migrene
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5. Mediu:
familial________________________________________________________________________
social_________________________________________________________________________
profesional_____________________________________________________________________
6. Semne vitale: TA__________ glicemie____________ Mg______________Ca____________
inaltime__________greutate______IMC_______modificari greutate in ultimul an (>10 kg)___
7. Zona de durere:
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Durerea 1: Localizare_______________________________Data aparitiei durerii___________
Circumstante de debut_____________________medicatie (tip/doza/prescriere)_________
Durata: __minute/ore; Frecventa: ___/zi____/sap___/luna ; Moment: [] dimineata, [] zi, [] seara
Intensitate:
0___________________________________________________________________________10
Tip 1: _________________ Senzatie 2:______________Tip 3: _______________ Reactie
emotionala 4: ____________ Evolutia durerii 5:___________Alte simptome 6:_______________
Factori agravanti 7:________________________Factori amelioratori 8:____________________
Durerea 2: Localizare_______________________________Data aparitiei durerii___________
Circumstante de debut_____________________medicatie (tip/doza/prescriere)_________
Durata: __minute/ore; Frecventa: ___/zi____/sap___/luna ; Moment: [] dimineata, [] zi, [] seara
Intensitate:
0__________________________________________________________________________10
Tip 1: _________________ Senzatie 2:______________Tip 3: _______________ Reactie
emotionala 4: ____________ Evolutia durerii 5:___________Alte simptome 6:_______________
Factori agravanti 7:________________________Factori amelioratori 8:____________________
Durerea 3: Localizare_______________________________Data aparitiei durerii___________
Circumstante de debut_____________________medicatie (tip/doza/prescriere)_________
Durata: __minute/ore; Frecventa: ___/zi____/sap___/luna ; Moment: [] dimineata, [] zi, [] seara
Intensitate:
0___________________________________________________________________________10
Tip 1: _________________ Senzatie 2:______________Tip 3: _______________ Reactie
emotionala 4: ____________ Evolutia durerii 5:___________Alte simptome 6:_______________
Factori agravanti 7:________________________Factori amelioratori 8:____________________
1. difuza, intepatoare, vibratorie, pulsatorie, apasatoare, stransoare
2. de caldura, de rece, de inghet, de arsura, de mancarime, de usturime
3. difuza, radianta, lancinanta, migratorie, intepatoare
4. de oboseala, de sufocare, de teama, de pedeapsa
5. stationara, paroxistica
6. anestezie, afectare vedere, afectare auz, afectare miros, lacrimare
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7. masticatie, vorbire, periaj, intoarcerea capului, bruxism
8. cald, rece, vacanta, medicatie
8. Evaluarea capului si gatului
a. Evaluare nervi cranieni:
[ ] I_____________________________________
[ ] II____________________________________
[ ] III, [ ] IV,[ ] VI_______________________
[ ] V____________________________________
[ ] VII__________________________________
[ ] VIII__________________________________
[ ] IX___________________________________
[ ] X____________________________________
[ ] XI___________________________________
[ ] XII__________________________________
b. Evaluare reflexe:
[ ] corneean______________________________
[ ] palatal________________________________
[ ] faringian______________________________
c. Evaluare ochi___________________________
d. Evaluare ureche_________________________
e. Evaluare cervicala:
- rotire dreapta ______ rotire stanga _______(70°)
- extensie________(60°) flexie ___________(45°)
- aplecare cap dreapta______ stanga _______(40°)
9. Palpare mm. capului si gatului si ATM (durere provocata de palpare 0=deloc ; 3 =nu pot atinge)
Dreapta Stanga
Mastoida 0 1 2 3 0 1 2 3
a. Muschi extra-orali si cervicali
M. temporal posterior 0 1 2 3 0 1 2 3
M. temporal mijlociu 0 1 2 3 0 1 2 3
M. temporal anterior 0 1 2 3 0 1 2 3
M. maseter - origine-unghiul mandibulei 0 1 2 3 0 1 2 3
M. maseter - corp 0 1 2 3 0 1 2 3
M.maseter - insertie 0 1 2 3 0 1 2 3
M. trapez 0 1 2 3 0 1 2 3
M. SCM 0 1 2 3 0 1 2 3
b. ATM
Pol lateral 0 1 2 3 0 1 2 3
Pol posterior 0 1 2 3 0 1 2 3
c. Muschi intra-orali
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M. pterigoidian lateral 0 1 2 3 0 1 2 3
M. pterigoidian median 0 1 2 3 0 1 2 3
M. digastric 0 1 2 3 0 1 2 3
M. temporal - tendon 0 1 2 3 0 1 2 3
10. Mobilitatea mandibulara lateralitate si propulsie
Deschid. activa________mm [ ] fara durere[ ] durere provocata[ ] durere identica cu durerea habituala
Deschid. pasiva________mm [ ] fara durere[ ] durere provocata[ ] durere identica cu durerea habituala
Endfeel [ ] soft [ ] hard
DVO___________mmOverjet ________mmOverbite________mm
Propulsie_______mm [ ] fara durere[ ] durere provocata
[ ] durere identica cu durerea habitualaPropulsie contra rezistentei dureroasa________Interferente in propulsie___________________
Lateralit. dr.______mm[ ] fara durere[ ] durere provocata
[ ] durere identica cu durerea Lateralit.dr. contra rezistentei dureroasa_______Interferente in lat dr_______________________
Lateralit. stg.______mm [ ] fara durere[ ] durere provocata
[ ] durere identica cu durerea habituala Lateralit.stg.contra rezistentei dureroasa______Interferente in lat stg _____________________ Excursie din RCin IM_____mm [ ]disconfort
[ ] confortDaca ∃ diferenta IM-RC: [ ] inspre sagital [ ] deviat dreapta
[ ] deviat stanga
Vreuna din miscarile efectuate v-a declansat durere de cap? ○ da ○ nuDaca da, care? ____________________________________________________
11. Zgomote ATM
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Doctor Pacient Durere Durere existentaZgomote Cracmente Zgomote Cracmente
Deschidere ATM stanga
ATM dreapta
Inchidere ATM stanga
ATM dreapta
Lateralitate stanga
ATM stanga
ATM dreapta
Lateralitate dreapta
ATM stanga
ATM dreapta
Propulsie ATM stanga
ATM dreapta
12. Blocaje articulare
Cand vi se intampla sa vi se blocheze articulatia?[] la deschiderea gurii[] la inchiderea gurii
Care dintre ele?[] ATM dreapta[] ATM stanga
Frecventa:_________________________________Data primului episod:__________________
13. Oglinda dentara
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14. Ocluzia de obisnuinta 15. Semne de instabilitate ocluzala[ ] stabila [ ] instabila [ ] Mobilitate crescuta dinti[ ] contact interincizal [ ] Fremitus[ ] non-ocluzie intermolara [ ] Abraziune / atritie severa[ ] distanta insuf. interocluzala [ ] Leziuni de colet severe[ ] contacte premature [ ] Recesii gingivale[ ] dinti rotati [ ] Feston McCall[ ] dinti inclinati [ ] Fisuri Stillman[ ] dinti supraerupti [ ] Impresiuni dentare pe limba[ ] dinti inghesuiti [ ] Afectiuni ale mucoasei bucale
Vi se pare comfortabila pozitia in care inchideti gura? ○ da ○ nuIndicele Helkimo______________________________________
16. Uzura dentaraEroziuni (dinti: _______________________Uzura (dinti: _________________________Abraziuni (dinti: ______________________Bruxism diurn (diagnostic posibil / probabil / demonstrat)Bruxism nocturn (diagnostic posibil / probabil / demonstrat)
17. Informatii despre limba: pozitie: ______dimensiuni: ___________tonicitate__________
18. Informatii suplimentare: ________________________________________________________________________________________________________________________________________________________________________________________________________________
19. Diagnostic
[ ] I a. Durere miofaciala[ ] I b. Durere miofasciala cu limitarea deschiderii gurii
[ ] II a. Deplasare discala reductibila[ ] II b. Deplasare discala ireductibila cu limitarea deschiderii gurii [ ] II c. Deplasare discala ireductibila fara limitarea deschiderii gurii
[ ] III a. Artralgie[ ] III b. Osteoartrita[ ] III c. Osteoartroza
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Plan de tratament:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Control 1: Data:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Control 2: Data:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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