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FICHA CLNICA INTEGRAL

Alumno: _______________________________________

Fecha:_________________

Docente: ______________________________________

IDENTIFICACIN DEL PACIENTE:


Nombre:_______________________________________________
Direccin: ______________________________________________
RUT:____________________________

Edad:_________________
Comuna:_______________

MOTIVO DE CONSULTA:
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ANAMNESIS PRXIMA
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Clasificacin ASA:_________________________________________________________________
Nombre y telfono medico tratante:_________________________________________________

ANAMNESIS REMOTA
Antecedentes mrbidos:
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Antecedentes quirrgicos:
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Frmacos:
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Alergias: ATB:____
analgsicos:____
anestsicos:____
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FICHA CLNICA INTEGRAL


Hbitos:
Tabaco:___
Alcohol:___
Drogas:____
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ANAMNESIS REMOTA FAMILIAR:


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ANAMNESIS ODONTOLOGICA:
Principal causa de prdida de dientes:________________________________________________
Antecedente traumticos: __________________________________________________________
Antecedentes quirrgicos: __________________________________________________________
ltimo control dental: __________________ Especialidad: _______________________________
Higiene Bucal: _________________________ seda dental:______________ Colutorios:________
Alergias a materiales odontolgicos:__________________________________________________
Hbitos o Parafunciones:___________________________________________________________
Portador de prtesis: Fija__________________
Removible:_________________________
EXAMEN FISICO:
1. General:
Deambulacin:___________________________________________________________________
Ubicacin temporoespacial:________________________________________________________
Posicin postural:_________________________________________________________________
Piel y anexos:_____________________________________________________________________
Signos Vitales: ____________________________________________________________________
2. Segmentario:
Craneo:__________________________________________________________________________
Cara:____________________________________________________________________________
Cuello:__________________________________________________________________________
Ojos: ___________________________________________________________________________
Nariz:___________________________________________________________________________
Labios: __________________________________________________________________________
Asimetras: ______________________________________________________________________
Perfil:___________________________________________________________________________
Biotipo Facial:____________________________________________________________________

FICHA CLNICA INTEGRAL


3. ATM
Ruidos:_______________________ Lateralidad ____ Apertura____ Cierre_____
Crepito: ______
Dificultad para abrir la boca:______
Dolor en apertura o lateralidad: ________
Fatiga o dolor muscular: __________
Disminucin de la apertura: __________
Desviacin o deflexin al cierre:___________
4. Msculos faciales y masticatorios:
Dolor a al palpacin:
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EXAMEN FISICO INTRAORAL:


Labios:__________________________________________________________________________
Borde bermelln: _________________________________________________________________
Comisuras:_______________________________________________________________________
Vestibulos:_______________________________________________________________________
Cara interna mejillas:______________________________________________________________
Frenillos:________________________________________________________________________
Lengua:_________________________________________________________________________
Piso de Boca:_____________________________________________________________________
Paladar Duro: ____________________________________________________________________
Paladar blando: __________________________________________________________________
Encas: __________________________________________________________________________
Rebordes alveolares:
Mucosas:__________________________________________________________________
Forma: ___________________________________________________________________
Clasificacin: ______________________________________________________________
Clasificacin Kennedy:
Maxilar: ________________________________________________
Mandibular: ____________________________________________
Anomalas dentomaxilares: _________________________________________________________
Saliva: Normal____ Disminuido ___
Aumentado ____

FICHA CLNICA INTEGRAL


ODONTOGRAMA

1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.1
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
3.8
3.7
3.6
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FICHA CLNICA INTEGRAL


3.5
3.4
3.3
3.2
3.1
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8

EXAMEN ENDODONTICO
EXAMEN CLINICO EXTRAORAL:
Cambios de color:_______

Aumento de volumen: ____________


Localizado______
Difuso_________
Duro__________
Fluctuante______
Adenopatas: ________________________________________________________
SIGNOS Y SINTOMAS DE PIEZAS AFECTADAS
Dolor:
espontaneo___________
Provocado ___________
Leve_________________
Moderado____________
Severo______________
Localizado____________
Irradiado_____________
Duracin_______________________________________________________________
Aliviado por ____________________________________________________________
Estmulos dolorosos:
________________________________________________________________________________
________________________________________________________________________________
Diente suelto _____________ Diente elongado______________
Aumento de volumen _____________________________________________________________
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FICHA CLNICA INTEGRAL


Cambio color coronario ___________________________________________________________
Caries __________________________________________________________________________
Superficial____ profunda______ penetrante______ cavitada__________
Obturacin _____________________________________________________________________
Superficial____ profunda______ penetrante______
Movilidad ______________________________________________________________________

EXAMEN RADIOGRAFICO
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TEST ENDODONTICOS
Frio____________________________________________________________________________
Calor____________________________________________________________________________
Vitalometro______________________________________________________________________
Percusion________________________________________________________________________
Otros____________________________________________________________________________
DIAGNOSTICO:
________________________________________________________________________________
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TRATAMIENTO:
________________________________________________________________________________
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EXAMEN PERIODONTAL
ANTECEDENTES DE ENFERMEDAD PERIODONTAL
Dolor: __________________________________________________________________________
Hemorragia: _____________________________________________________________________
Movilidad dentaria: _______________________________________________________________
Antecedentes familiares: ___________________________________________________________
HBITOS
________________________________________________________________________________
________________________________________________________________________________
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FICHA CLNICA INTEGRAL


HIGIENE
Frecuencia: ______________________________________________________________________
Tipo de cepillo: ___________________
Complemento:_____________________________

EXAMEN RADIOGRAFICO
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CARACTERISTICAS DE LA ENCA:
Color:___________________________________________________________________________
Forma: __________________________________________________________________________
Posicion: ________________________________________________________________________
Tamao: ________________________________________________________________________
Consistencia y Superficie: __________________________________________________________

INTERCONSULTAS:
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DIAGNSTICO:
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FICHA CLNICA INTEGRAL


PRONSTICO:
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PLAN DE TRATAMIENTO:
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FICHA CLNICA INTEGRAL


ANALISIS OCLUSAL DE MODELOS
1. ANALISIS DE MODELOS POR SEPARADO
Piezas ausentes (especificar motivo):
________________________________________________________________________________
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Piezas migradas, direccin y posibles motivos:
________________________________________________________________________________
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Piezas desalineadas y direccin (versada, girada, giroversada)
________________________________________________________________________________
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Forma de arco:
Maxilar:____________________________
Mandbula: _________________________
Lneas medias coincidentes con lnea media maxilar:
________________________________________________________________________________
________________________________________________________________________________
Altura cuspidea: __________________

Direccin de los surcos:______________________

Indicar que piezas presentan:


Fracturas: _________________________________________________________________
Cavidades: ________________________________________________________________
Facetas de desgaste:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
(Especificar qu tipo de facetas de desgaste)

FICHA CLNICA INTEGRAL


2. ANALISIS ESTATICO DE MODELOS ARTICULADOS
Coincidencia de RC y MIC: __________
Contactos prematuros:
________________________________________________________________________________
________________________________________________________________________________
Cantidad y direccin de desplazamiento en cntrica (mm):
Vertical: :___________
Sagital: ____________
Clasificacin de Angle:
Canina derecha: ____________
Molar derecha: _____________

Lateral: __________________

Canina izquierda: ________________


Molar izquierda: _________________

Relacin intermaxilar:
Horizontal: Overjet (mm) ___________
vis a vis______
cruzada_____
Vertical: Overbite (mm) ___________ vis a vis_____ Abierta_____ Invertida_____
Relacin dentaria posterior:
Derecha: 1:1_____________________________________________________________
2:1_____________________________________________________________
Izquierda: 1.1_____________________________________________________________
2.1_____________________________________________________________
3. ANLISIS DINAMICO DE MODELOS ARTICULADOS
Protrusin: (piezas que contactan y piezas que interfieran en la desoclusin)
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Lateralidad: (piezas que contactan y piezas que interfieran en la desoclusin)
________________________________________________________________________________
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Gua de desoclusion:_______________________________________________________________
Escuela: _________________________________________________________________________
DIAGNSTICO OCLUSAL:
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