1. Requirements for writing dental medical records

(1) Medical history

General requirements for medical record records have been detailed in general medical records and general surgical medical records, but attention must be paid to The following items:

1. Nutritional status and related bad habits in childhood.

2. Oral hygiene, disease history, surgical history and treatment process.

3. Family history: Ask the patient if any of his immediate relatives have ever suffered from cancer, diabetes, tuberculosis, congenital malformations and other diseases.

(2) Physical examination

The specialist examination, that is, oral and maxillofacial conditions, should be described in detail:

1. Teeth

(1) The recording symbols of the tooth parts are represented by numbers in the upper, lower, left and right areas according to the order of tooth position, from front to back, using cross-shaped lines, and are recorded in each area respectively. Permanent teeth are represented by Arabic numerals and deciduous teeth are represented by Roman numerals. See table below.

(2) Shape, number, color and position. Pay attention to the shape, size of teeth, whether there are deformities, missing teeth and supernumerary teeth; whether the color is normal; whether there is crowding, sparseness, dislocation, tilt or obstruction. Health and other situations.

(3) Normal physiological looseness does not count in degrees. Those who are greater than the physiological looseness but not more than 1 mm are classified as I°. Those whose looseness is equivalent to 1 to 2 mm are classified as II°. Those whose looseness is greater than If it is 2 mm, it is classified as III°, and if it is abnormally loose and floats up and down, it is classified as IV°.

(4) Dental defects and lesions: Record the name, tooth position, scope and extent of the lesions, and conduct temperature, electrical energy or local anesthesia tests if necessary to identify the location and nature of the lesions.

(5) Restoration status: Whether there are fillings, artificial crowns, fixed bridges, dentures, etc. Pay attention to their tightness and whether there are secondary lesions.

(6) Occlusion relationship: record normal, reverse, locked (cross), super, deep overlap, opposite edge, open and low gap, etc.

(7) Missing teeth situation: number and location of missing teeth, and healing status of tooth extraction wounds.

2. Gingiva

(1) Shape, color and toughness. Pay attention to whether there is inflammation, ulceration, swelling, necrosis, hyperplasia, atrophy, fistula, whether the color is normal, and whether it is easy to bleed. .

(2) Blind pocket situation Blind pockets are divided into two types: gingival pockets and periodontal pockets (supraosseous pockets, infraosseous pockets). Record their location and range, and measure their depth, calculated in mm. Is there any secretion in the blind bag?

(3) Tartar is divided into two categories: supragingival and subgingival. Pay attention to its location and degree. Supragingival calculus can be divided into small amount (+), medium amount (++), and large amount (+++). ) (There is a lot of tartar or it is also attached to the teeth).

3. Pay attention to whether the lips and mucous membranes have abnormal color and shape, whether there are herpes, cracks, desquamation, keratosis, congestion, bleeding, ulcers, erosion, scabs, induration, deformities, etc., and record them location, size and extent.

4. Tongue, pay attention to the size and color of the tongue body, whether there are indurations, ulcers, lumps, and imprints, whether it is soft and swollen, whether there is tongue coating and its color and thickness, and whether there are cracks or keratinization on the back of the tongue. Are there any abnormalities in the nipples, whether there are any obstacles to the movement and sensory functions of the tongue, and whether the tongue tie is too short.

5. Palate: Pay attention to whether there are fistulas, congestion, keratinization, erosion, ulcers, masses, deformities, etc., and whether there are any obstacles to the movement of the soft palate.

6. Whether the salivary glands and their ducts are swollen, tender, blocked, congested, pus overflowing, external fistulas, etc.

7. Lymph nodes Pay attention to the number, size, hardness, mobility, tenderness, etc. of lymph nodes in each group of lymph nodes in front of the ear, behind the ear, cheek, submental, submandibular and neck.

8. On the face, observe whether the expression and appearance are symmetrical, whether there are deformities, defects, swelling, scars, fistulas, color changes, and identify painful and numb areas (you can take photos or draw simple diagrams to explain).

9. Jaws: Check the appearance of the upper and lower jaws respectively to see whether the two sides are symmetrical, whether there are deformities, swelling, tenderness, defects and disconnections, etc. Pay attention to the bite and opening conditions.

10. Pay attention to the shape and movement of the temporomandibular joint, whether there is tenderness or snapping, and compare the two sides. When mouth opening is restricted, the extent is indicated by the number of centimeters between the incisal edges of the upper and lower incisors when the mouth is opened.

Name:**

Gender:**

Age:**

Main Complaint: Upper right posterior tooth pain due to cold stimulation and pain at night 3rd day

History of current illness: The right upper back tooth has been experiencing severe pain when exposed to cold water for the past three days, and the pain worsened at night, so he came to our hospital for treatment.

Past history: None

< p>Examination: The distal caries of the upper right first molar are deep into the dentine layer, probing (++), percussion (-), hot and cold diagnosis (+++), the periodontal periodontal condition is normal and there is no calculus, the color of the gums is normal, and the teeth are loose. The remaining teeth are normal and the oral hygiene is good. Pulp treatment

Processing: Open pulp under local anesthesia, remove coronal pulp, rinse with hydrogen peroxide, rinse with normal saline, and temporarily seal with CP zinc oxide clove oil.

Doctor’s instructions: follow-up visit in one week< /p>

Doctor’s signature:

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