6. Table of contents of lecture material.

The health centre system is an active method of dynamic supervision on the state the health of both almost healthy population and patients that have chronic and of long duration diseases.

A clinical method of supervision is the system of the prophylactic and curative measures, sent to strengthening of health, improvement of physical development, active exposure of diseases on the early stages, systematic supervision on the state the health of the persons, taken on a clinical supervision, grant to them of timely curative help, maintenance of their capacity, and also active prophylaxis of complications of diseases, id est on realization of active measures of individual and social prophylaxis, making healthy of productive and domestic terms.

The health centre system of patients of stomatological profile is the system of curative measures, diseases of organs and fabrics of cavity of mouth and maxillufacial area sent to the as possible early exposure, liquidation of reasons, that cause these diseases, quality complex inspection, treatments of patients, that are on a clinical account, economies of their capacity. Organization of realization and account of clinical work in stomatology are regulated by the order of Ministry of health № 327 from 08.12.2000 «about proceeding in the health centre system of population and introduction of monitoring of the state of his health».

Principles of the health centre system of stomatological patients :

• development according to plan and complexity of medical and preventive measures;

• the differentiated approach is with the use of modern methods of diagnostics, treatment and prophylaxis of diseases of maxillufacial localization;

• permanent in-plant training of doctors.

Elements of the health centre system of stomatological patients :

• selection;

• supervision;

• making healthy;

• planning;

• management.

For surgeon-stomatology patients are subject a clinical supervision from:

• by the precancer diseases of jaws, organs and tissues of cavity of mouth;

• malignant new formations of jaws and cavity of mouth (jointly with oncologists depending on the stage of disease).

Order and methods of inspection of oncostomatological patient.

1. finding out of complaints and taking the history;

2. an objective inspection is with the use of physical methods;

3. application of additional methods of inspection.

At questioning of patient it follows to pay attention to complaints:

• heterospecific complaints, new formations (presence of tumour, asymmetry of face, deformation of organs and other) predefined by a presence;

• complaints are about heterospecific functional violations (difficulty of mastication, broadcasting, swallowing, change of timbre of voice, nasal breathing, during opening of mouth, during the turn of chairman, change of eyeball, loop of vision, numbness of certain areas of person and all.);

• pain is in the area of new formation (involuntary, causal, strong, moderate, weak, brief, protracted, permanent, aching, prickly and other);

• specific complaints (periodic bleeding at heamangiomas neurological symptomatology at the tumours of peripheral nerves, specific character of pain at ossiform osteoid-osteoma and other);

• complaints of general character (weakness, indisposition, loss of appetite and other).

After finding out of complaints of patient get to taking the history a disease and life:

• time of appearance of new formation or moment, when the patient of him noticed first;

• with what a patient links the origin of tumour;

• what the first signs were;

• rates of increase of new formation, growth acceleration, periods of increase-diminishing, joining of the used for setting fire phenomena, appearance of new symptomatology and other;

• whether a patient for medical help and her result applied;

• preliminary estimate of the state of health of patient;

• terms of labour and way of life;

• heredity and other

The study of Status of localis consists in a careful estimation:

• symmetries of face;

• to the state of skin canopies;

• functions of Temporal-mandibular joints;

• to the state of cavity of mouth, pharynx;

• functions of salivary glands and state of their channels;

• to the state of regional lymphatic knots (for the exception of lymphatic metastases at malignant tumours).

Methods of objective clinical research :

• review;

• palpation;

• percussion (teeth that is located in the area of new formations of jaws);

• auscultation (branchy heamangiomas, hemodectoma, vascular aneurysm - for the exposure of systole noise).

Sequence of description of new formation :

• localization;

• sizes;

• color;

• form and contours;

• state of surface;

• consistency;

• fluctuation;

• presence of characteristic symptoms (filling - evacuation, parchment crunch);

• a sickliness is at palpation;

• mobility;

• changes of skin and mucous membranes are above new formation.

Additional methods of inspection of patients with tumours and tumular new formations :

• roentgenologic;

• a computer tomography is with a 3D-modeling;

• MRI;

• cytological research (punction, stroke-imprint);

• biopsy (incisive, excisive, tongs);

• thermography;

• radioisotopic research;

• ultrasonic research;

• laboratory researches (to blood, urines and other).

Medical documentation:

Medical map of stomatological patient (form № 043/0) - is a current and registration document, contains columns with pointing of passport data, diagnosis of disease, complaints, anamnesis of disease and life of patient, data objective and additional methods of inspection, and also diary and treatment and prophylactic reviews of patient. Medical contains the executioner of stomatological patient to the list about the studies of patient to skills of hygiene and control of the hygienical state of cavity of mouth.

A sheet of daily account of work of doctor-stomatology (form №037/0) is a current and registration document, that is filled every day by a doctor after the reception of patients and contains information about actually exhaust business hours, amount of the accepted patients, diagnoses of patients and complex of the executed treatment taking into account the feasible anaesthetizing, information about sanation of cavity of mouth, conditional units of labour intensiveness are exhaust. On the basis of data of «Sheet of daily account of work of doctor-stomatology» at the end of month «Diary of account of work of doctor-stomatology» is filled.

A diary of account of work of doctor-stomatology (form № 039-2/0) is a current and registration document, that contains a 51 column with information about exhaust during a month business hours, amount of the accepted patients, volume of the produced curative and prophylactic work. A diary is filled at the end of working month and serves for statistical treatment of results and account of work of doctor-stomatology.

A magazine of account of prophylactic reviews of cavity of mouth (form № 049/0) is a current and registration document that represents prophylactic work of doctor-stomatology with the proper groups of patients, characterizes the state of clinical work of stomatological establishment.

Epidermal cyst. This cyst behaves to the group of kerato-cysts. Before she was described under the name atheroma. An epidermal cyst is mostly localized on the skin of face, neck, hairy part of chairman. It is single or plural, quite often acne is preceded an origin vulqaris. Formation of cyst is related to corking of the deferent opening of follicles of oil-gland. She slowly increases because of accumulation of keratin that products shell.

Clinically a cyst appears as limited rounded-oval education. It is situated under an epidermis and closely with him soldered in area of deferent channel of oil-gland. A skin above a cyst sometimes becomes blue tint and stretches at her largenesses. At palpation cyst of elastic consistency, painless. Content of her presents characteristic pappy mass of white color. A cyst can be purulent often, pain appears here, she increases, surrounding fabrics filling out and hyperemic.

Microscopically an epidermal cyst is deported by a multi-layered flat epithelium and filled by the layers of keratin.

Treatment. A cyst is deleted with a capsule, it is here necessary to carve two demiovoid cuts that meet inter se the area of skin, get with a cyst.

Dermatoid cyst. Appears as a result of teratosis and forming of face in the places of union for an embryo frontal, maxillary and mandibulary humps. It is usually situated in area of subchin, on the bottom of cavity of mouth, near a root and wings of nose, internal and external edges of eye socket, more often meets for young persons.

A dermatoid cyst is cavitas education with a thick coriaceous shell, by the filled pappy mass of dirtily-white color with an odor nuisance. Content of cyst consists of epidermis, foods of selection of, sweat oil-glands and hair follicle, sometimes with the presence of hair.

At a review tumular formation of the rounded form with clear limits, painless, is marked, not get with a skin or mucous membrane. Being situated on the bottom of cavity of mouth, it is determined strictly on a middle line above a jaw-subglossal muscle and examines with x-rays a rather yellow color. The cyst of largeness drives back a tongue up, a language and reception of meal become laboured.

Histological the shell of cyst contains the elements of skin, including the epidermal covering, hair follicles and, sweat oil-glands.

Treatment consists in moving away of cyst with a capsule. At a location cysts above a jaw-subglossal muscle conduct an operation внутрішньоротовим approach. The cyst of area of subchin is deleted through an external cut.

Bear cysts and fistulas of face and neck. Among them тіреоглосальні cysts and fistulas distinguish brachial (from gr. Branha are branchiaes). The origin of brachial cyst and fistula is related to the anomaly of development of 1th and 2th brachial cracks and arcs. Thyreoglossal cyst and fistula appear because of incomplete reduction for the embryo of thyroglossal channel. Bear cysts and fistulas meet comparatively rarely and, from our data, fold close 5% of all new formations of maxillufacial area. The anomaly of branchial cracks is observed more often to the thyreoglossal anomaly (accordingly 61 and 39% cases).

Bear cysts and fistulas meet mainly for children and persons of young age. Clinical motion of brachial and thyreoglossal cysts and fistulas alike, however they have the characteristic features conditioned by localization.

A cyst increases slowly, during a few years. It is determined as the painless limited formation of the rounded or oval form, to elastic consistency, not get with a skin. A cyst it is found out by chance or in case of occurring of inflammation. In case of joining of specific microflora (mycobacterium of tuberculosis, actinomycetess) diagnostics of hardness.

Bear fistulas can be complete, here are two deferent opening: external — on a skin internal — on the mucous membrane of cavity of mouth, and incomplete — with one mouth external or internal. In the diagnostician of fistulas contrasting fistulographia matters by means of iodlypol. She allows to define direction, slowness and presence of branches of fistula, knowledge of that is needed at surgical treatment.

Brachial cyst and fistulas. There are a cyst or fistula of parotid area at pathology of 1th branchial crack, related to the external acoustic duct and auricle. The anomaly of development of 2th branchial crack conduces to forming of lateral cyst or fistula of neck. Brachial of cyst and fistulas of parotid area meet considerably rarer than lateral cysts and fistulas of neck (accordingly in 11 and 89% cases).

Cyst and fistula of parotid area. A cyst is situated under the bulk of parotid salivary gland or in a mandibular area above the barrel of facial nerve and often has connection with the cartilaginous department of external acoustic duct. Clinical displays are such, as at an of high quality tumour or cyst of parotid salivary gland, content is the liquid of rather yellow color, sometimes turbid.

Bronchial fistula with the deferent opening located on a skin ahead of basis of frizz of auricle, name supraouricular. Often he is bilateral. the role of the inherited factor registers in his origin.

The fistula of позадущелепної area appears as a result of independent and operative section of purulent brachial cyst, external opening him is situated between the corner of bottom jaw and cutting edge of muscle strenoclaidomastoideus. At complete pre-ear and mandibular fistulas the second opening is opened on the skin of cartilaginous department of external acoustic duct, at the incomplete fistula of wall last intertwined for him. Macroscopically the internal covering of fistula and cyst of parotid area is presented by a multi-layered flat ороговіваючим epithelium.

Lateral cyst and fistula of neck. A cyst is a cavity with liquid content and comparatively thin shell. She has typical localization, is situated in middle third of neck ahead strenoclaidomastoideus muscle, on a vascular-nervous bunch, directly joining to the internal jugular vein, with a skin not soldered. Especially well contouring at the turn of chairman sick in an opposite side. Content of cyst is the turbid liquid of rather yellow color, at cytological research of that oxyphilic is determined fine-grained mass with the elements of multi-layered flat epithelium and far of lymphocytes.

Microscopically the wall of cyst is deported by a multi-layered flat epithelium.

Diagnostics of lateral cyst is base on anamnestic and clinical data. A receipt at punction of plenty of characteristic content (5-30 mls and more) and data of cytological research allow to confirm the diagnosis of lateral cyst

A lateral fistula of neck is one-sided and rarely bilateral. It appears in one cases at birth of child, in another cases is the result of section of purulent lateral cyst of neck. The external mouth of fistula is situated on the skin of side of neck according to the cutting edge of strenoclaidomastoideus muscle. The internal mouth of complete lateral fistula has permanent localization in the overhead pole of palatal amygdale At back a fistula passes between external and internal sleepy arteries.

Clinically an external mouth of fistula can be a point or extended with bursting granulation, sometimes covered by getting wet crusts. A polychromia and maceration of skin are determined round a fistula from that a rather yellow viscous liquid is constantly distinguished in a negligible quantity. In case of complete lateral fistula patients often specify in anamnesis on a recrudescent one-sided quinsy, at a review determine the increase of amygdale of corresponding side.

The lateral fistula of neck needs to be differentiated from a middle thyreoglosal fistula, the external mouth of that is sometimes displaced aside from a middle line, and specific inflammatory process.

The microscopic picture of covering of fistula answers the structure of wall of lateral cyst of neck.

Thyreoglosal cyst and fistula have typical localization on the middle line of neck, in this connection they are named also middle.

Thyreoglosal cyst is situated on the middle line of neck in under- or to the supersubglossal area and in the root of tongue. At localization on a neck the limited mobility of cyst and cohesion of her are determined with the body of hyoid that clearly appears at swallowing. At the cyst of root of tongue the last is brought, violation of language and difficulty of swallowing are marked.

Infecting of content of cyst leads painfully, will be swollen, infiltrations of surrounding fabrics.

Content of thyreoglosal cyst presents a turbid rather yellow viscous liquid. Cytological research is set the presence of cages of multi-layered flat epithelium and limthoid elements. The epithelium of shell of cyst, as well as covering of middle fistula, has a endodermal origin.

Thyreoglosal fistula arises up, as a rule, after the involuntary or operative section of middle cyst of neck the External mouth of fistula is situated on a skin on the middle line of neck, mainly between a hyoid and thyroid cartilage. A skin is often in scars, sometimes granulation overgrows round a fistula. The wretched is marked слизоподібне separated. At a complete fistula an internal mouth is situated in area of foramen coecum.

Thyreoglosal fistula passes on the middle line of neck, breaks through the body of hyoid and under the corner of 40-45° heads for the blind opening of tongue. At palpation fistula motion, equal as and middle cyst of neck, always related to the body of hyoid. Determine it thus. Retaining fingers a fistula or cyst, ask a patient to swallow saliva, here a change together with the hyoid of the fixed educations talks about the presence of thyreoglosal fistula or cyst.

Differential diagnostics of middle cyst and fistula is conducted with a specific inflammatory process, lymphadenitis, dermatoid cyst, from a tongue or by the adenoma of dystopia of thyroid.

Treatment. At a cyst conduct the complete moving away with a capsule. At presence of inflammation an operation is carried out after his liquidation. A cyst behind a jaw area is deleted through a cut that rounds the corner of bottom jaw, and giving up him on a 1,5-2 cm low, not to injure the regional branch of facial nerve. For moving away of lateral cyst to the neck conduct the cut of skin above a cyst on the cutting edge of strenoclaidomastoideus muscle or on an overhead neck fold. At a thyreoglosal cyst to the neck unseal a skin on the overhead or middle fold of neck, moving away of cyst combine the bodies of hyoid with a resection. The cyst of root of tongue depending on sizes is operated or by a intraoral, or by external approach.

Filling of him is preceded moving away of fistula before the operation of 1% by water solution methylene blue. Thus the wall of fistula is painted and well traced during moving away. An operation consists in the complete moving away of fistula with his branches. Conduct a cut that rounds the external mouth of fistula, him prepared and distinguish a fistula. Moving away pre-ear and mandibular fistulas completed by moving away of area of cartilaginous department of external acoustic duct. An operation at the complete lateral fistula of neck is related to the certain difficulties related to topographical interrelation of fistula and vascular-nervous bunch : fistula motion passes in the lodge of him between external and internal sleepy arteries. Moving away of thyreoglosal fistula, as well as cysts, is accompanied by the resection of body of hyoid.