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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