牙周病的治療預(yù)后、計(jì)劃分析解析

1、QUESTION？,Is my disease fatal?Will I lose my teeth?Will your treatment help me?What can you do to help me?,第 11 章 PROGNOSTIC JUDGMENT TREATMENT PLANNING,牙周病的預(yù)后和計(jì)劃,PROGNOSIS,Prognosis??Forecast預(yù)后??預(yù)測(cè),預(yù) 后 類(lèi) 型,整體預(yù)后依據(jù),病

2、史、年齡,疾病類(lèi)型 發(fā)展速度,全身因素 環(huán)境因素,患者意愿、依從性,菌斑 牙石量 解剖,牙周破壞程度,,,,,,,有全身因素的牙齦炎全身因素控制后可以痊愈,齦炎的預(yù)后單純性齦炎：良好,牙周炎的預(yù)后,總預(yù)后個(gè)別牙預(yù)后,牙周炎總預(yù)后對(duì)整個(gè)牙列預(yù)后的評(píng)估，內(nèi)容包括,牙周炎的類(lèi)型單因素輕中度CP，療效易鞏固有全身因素的牙周炎，變化多樣,骨破壞的速度、程度、類(lèi)型,局部因素消除情況: 菌斑、根分叉問(wèn)題、咬合牙松動(dòng)余留

3、牙的數(shù)目、分布；患者依從性環(huán)境與行為因素全身、遺傳、年齡因素,牙周炎個(gè)別牙預(yù)后,探診深度、附著水平：部位？程度？袋深淺不是決定的因素。牙槽骨：破壞部位、程度、根分叉病變；牙松動(dòng)度：自限性？進(jìn)行性牙松動(dòng)？牙解剖：,牙周病治療計(jì)劃,總體目標(biāo),控制菌斑、炎癥合理的牙周組織形態(tài)糾正：牙周袋 齦退縮骨缺損 牙松動(dòng)牙齒及鄰接關(guān)系,恢復(fù)牙周組織功能合理的咬合關(guān)系修復(fù)失牙戒除不良習(xí)慣,維持長(zhǎng)期療效防復(fù)發(fā)口腔衛(wèi)

4、生指導(dǎo)與菌斑控制定期檢查,治療程序,主要分為四個(gè)階段,第一階段病因治療,基礎(chǔ)治療INITIAL THERAPY消除、控制：致病因素臨床炎癥,包括下列方法：,自我控制菌斑的方法：刷牙方法和習(xí)慣；牙線和牙簽；菌斑顯示劑檢查漱口劑,拔除病牙,潔治、刮治、根面平整術(shù)藥物控制感染咬合調(diào)整,治療齲齒，矯正不良修復(fù)體和食物嵌塞,處理牙周-牙髓病變,1st階段結(jié)束后4~6周再評(píng)估，確認(rèn)療效、依從性、治療方案,第二個(gè)階段,牙周手術(shù)

5、治療并非每個(gè)患者都要進(jìn)行,牙周手術(shù)目的,清除袋內(nèi)感染物根面平整治療牙槽骨缺損糾正齦及膜齦畸形基礎(chǔ)治療后1~3月全面評(píng)估,手術(shù)的種類(lèi),牙齦切除術(shù)切除肥大增生的牙齦病理性牙周袋,翻瓣術(shù),牙周骨手術(shù)骨修整術(shù)、植骨GTR膜齦手術(shù)牙種植術(shù),第三階段修復(fù)治療階段并非每個(gè)患者都要進(jìn)行,2st階段后2~3月進(jìn)行松牙固定義齒修復(fù)、正畸,第四階段療效維護(hù)期,1st階段后無(wú)論是否需要進(jìn)行2、3階段治療即應(yīng)當(dāng)開(kāi)始，內(nèi)容包括：,定

6、期復(fù)查,時(shí)間：一般3~6個(gè)月1次。 內(nèi)容：PLI、CI、DI、GI、BOP、PD、附著水平、牙松動(dòng)度、咬合情況、骨高度、密度、危險(xiǎn)因素：吸煙、全身疾病,復(fù)治,根據(jù)發(fā)現(xiàn)的問(wèn)題進(jìn)行新一輪的治療與療效維護(hù),牙周治療與院內(nèi)感染,P163-164自學(xué),OVERTHANKS,牙周治療與院內(nèi)感染交叉感染 是醫(yī)院內(nèi)感染(NOSOCOMIAL INFECTION)中的重要內(nèi)容之一。,醫(yī)院感染的傳播途徑有：,直接接觸病損、血液、體液、齦溝

7、液、菌斑等；吸人含致病菌的氣霧或飛濺物(如血液、唾液等)；間接接觸(污染器械、手、治療臺(tái)等傳染媒體)；手機(jī)供水管道中的存水返流人口中。,我國(guó)人群中HBV攜帶者約占10%，艾滋病、梅毒等也有增多的趨勢(shì)。,牙周診室控制感染特點(diǎn)及原則,病史采集及必要的檢查重視詢(xún)問(wèn)全身疾病、傳染性疾病?！耙恢聦?duì)待”原則universal precaution即假定每位患者均有血源性傳播的感染性疾病，診治中一律嚴(yán)格防交叉感染，必要時(shí)作有關(guān)的化

8、驗(yàn)檢查。,治療器械的消毒 按器械分類(lèi)、分別用不同的方法消毒。 “雙消毒”：對(duì)使用過(guò)的器械應(yīng)實(shí)行消毒液浸泡、超聲波或手工清洗、清水沖凈干燥、高壓滅菌或其他消毒方法。大型設(shè)備如綜合治療臺(tái)表面等，可用可靠的消毒劑進(jìn)行表面擦拭等。,應(yīng)盡量使用已消毒的一次性用品(如檢查器、吸唾器、注射器等)。一人一機(jī)。也可2%碘酊擦拭手機(jī)的各部位，酒精脫碘2次，也可用1%碘附消毒。,保護(hù)性屏障口罩、帽子、防護(hù)眼鏡、面罩、手套、工作服等治療過(guò)

9、程中，污染的手套不得任意觸摸周?chē)奈锲罚委熃Y(jié)束后應(yīng)清洗手套上的血污后再摘除手套，書(shū)寫(xiě)病歷等。,盡量使用腳控開(kāi)關(guān)來(lái)調(diào)節(jié)治療椅照明燈扶手、開(kāi)關(guān)等可用一次性覆蓋物覆蓋。一次性器械及覆蓋物在用畢后應(yīng)妥善、單獨(dú)回收，作必要的銷(xiāo)毀。,減少治療椅周?chē)諝庵械募?xì)菌量治療前1%過(guò)氧化氫或0.12%氯己定液鼓漱一分鐘，減少患者口中的細(xì)菌數(shù)量、治療時(shí)的氣霧污染。診室內(nèi)應(yīng)有良好的通風(fēng)。不在診室內(nèi)飲水和進(jìn)食。,治療臺(tái)水管系統(tǒng)的消毒、阻止水回流的

10、裝置；在每位患者治療結(jié)束后，再空放水30秒；每天開(kāi)始工作前再?zèng)_水一至數(shù)分鐘。國(guó)外建議超聲波潔牙機(jī)使用單獨(dú)的凈水儲(chǔ)水器，并每周用1:10的次氯酸鈉液沖儲(chǔ)水系統(tǒng)，隨后立即用蒸餾水沖洗。,嚴(yán)格遵守控制醫(yī)院感染的原則，使病原微生物的擴(kuò)散和環(huán)境的污染降低到最小的程度。保護(hù)患者和醫(yī)務(wù)人員的利益安全。,Treatment can alter prognosis.,Prognosis has different connotations an

11、d nuances.,The patient has every right to know the answers to these questions.,Question？,Is my disease fatal?Will I lose my teeth?Will your treatment help me?What can you do to help me?,What are the therapeutic "

12、odds"?What are the financial risks? What are the chances that the treatment will be of benefit?,Prognosis has three meanings in dentistry.,Diagnostic prognosis.,What are evaluations of the cour

13、se of the disease without treatment? What is the status of the teeth nowWhat is the anticipated future of these teeth?,Therapeutic prognosis.,Given the state of the art and science of periodontics and the knowledge and

14、 skill of the practitioner, what effect will periodontal treatment have on the course of the disease?,Prosthetic prognosis.,What is the forecast for the success of the prosthetic restoration?Will the prosthesis be thera

15、peutic or detrimental?What specific needs dictate that it be prescribed?,Judgement of the severity depends on ：,1. pocket depth, 2. degree of bone loss,3. tooth mobility,4. crown-root ratio.,generalized or localized,

16、The distribution of disease：Inflammatory factors ：Traumatic factors：,Individual tooth therapeutic prognosis,includes such factors as ：Percentage of bone loss; Probing depth;,Distribution and type of bone lossPresence

17、 and severity of furcation involvementsMobility,Crown-root ratioPulpal involvementTooth position and occlusalStrategic value,Following are factors included in overall prognosis:,AgeMedical status,Individual tooth pr

18、ognoses (distribution and severity)Degree of involvement, duration, and history of the disease (rate of progression),Patient cooperationEconomic considerationsKnowledge and ability of the dentistEtiologic factors,A

19、ccuracy and completeness of the information gathered at the examinationDentist's ability to recognize and eliminate or control the factors causing the disease,the patient's ability and determination in maintaini

20、ng the health of the periodontium and teeth.,The overall prognosis depends on the prognoses of the individual teeth.,PAST HISTORY (RATE OF DESTRUCTION),Probably the most important factor in forecasting the future health

21、 status of a dentition is knowledge of its past health status.,Speed of breakdown under controls or uncontrols The location, shape and depths of the pockets,Tooth mobility can be controlled or eliminated, the prognosis

22、is better.The greater the bone loss, the poorer the prognosis.,As bone loss exceeds 50%, the prognosis worsens rapidly.The more irregular the bone loss, the poorer the prognosis.,the pattern of bone loss: horizontal, v

23、ertical or infrabony defects.the age of the patient and the etiologic factors involved in the patient's disease.,poorer prognosis: tilted, drifted, or rotated, hygiene difficult, elimination of pockets impaired,per

24、iodontal disease is complicated by active systemic factors and traumatism,morphologic in nature and include the number and distribution of teeth, tooth morphology, furcation involvement.,Extent of involvement. Is the f

25、urcation partially or totally involved?Status of bone support. If the bone levels are relatively sound, the effort to save may be justifiable.,Root length and crown-root ratio must be considered,Angulation of root spre

26、ad. Health of neighboring teeth.,The number and distribution of teeth presentcrown-root ratio,shape and number of the root,the height of the alveolar crestpersonal psychologic and sociologic, financial consideration

27、s.,OTHER CONSIDERATIONS IN ESTABLISHING PROGNOSIS,The performance of home care is acceptable and the caries incidence is low,the prognosis is better,The prime consideration is the preservation of the dentition as a func

28、tioning unit.,In some instancesthe extraction of a single tooth will make the whole situation untenable.In other situations isolated extractions will simplify the problem.,what is considered to be a hopeless tooth. Th

29、is will make treatment planning simpler.,the characteristics of hopeless periodontally involved teeth:,Associated with intractable pain relieved, massive infection reduced by extractionMobility beyond 3 degrees,Furcatio

30、n involvement with little or no interradicularboneBone loss beyond the apexBone loss to the apex on one side of the tooth,Generalized circumferential bone loss to within 3 mm of the apexPocket depth to the apex withou

31、t pulpal involvementVertical cracks or fractures,Inaccessible perforations or accessory canalsNumber and position of remaining teeth precluding prostheticExtreme caries susceptibility,Objectivesof treatment,Treatment

32、 goals should be evaluated in every case.,Can treatment objectives of a firm non-retractable gingiva that does not bleed be reached? Can the pocket be eliminated? Will the bone regenerate? Can the tooth be stabilized?

33、,Can tooth be restored?Can the patient tolerate the treatment?,If you believe the answers to these questions to be "yes," then plan and proceed with the treatment. If “no,” alternative treatment, compromise,

34、or extraction is advisable.,As definitive laboratory tests are developed to make diagnosis more accurate, and as further knowledge concerning the etiology and pathogenesis of periodontal diseases is developed, prognosis

35、will change from a qualitative to a quantitative judgment.,TREATMENT PLAN,PresentationPatient consentOrder of treatmentPhase IPhases Il and IIIMaintenance therapyProsthetic prescription,Alternative treatment plansT

36、reatment criteriaQuality of carePhilosophy of treatmentRecord keepingReferral,PresentationPatient consentAfter hearing the presentation, the patient must decide whether to undergo treatment.,PHASE I,First steps (T

37、he initial effort) should be directed toward the elimination of inflammation and the institution of a program of plaque control.,To reduce pocket depthTo minimize periodontal traumatismOrthodontics(may precede or foll

38、ow any surgical interventions),Extractions(Teeth with hopeless prognoses)RestorationsUsually periodontal therapy should precede restorative interventions. the restorations should be temporary,The provisional splinting

39、 during the treatment period should be evaluated.,Scheduling of restorative treatment should be done according to the following general rules:,Normal patients. (Restorative treatment starts immediately.)Class I (ADA

40、periodontal disease classification),Without occlusal treatment needCaries control and scaling and root planning. including plaque control, may be simultaneous. Definitive restorative treatment should follow completion o

41、f scaling and plaque control.,With occlusal treatment need Definitive restorative treatment may immediately follow completion of scaling, plaque control, and occlusal adjustment.,With surgical treatment need Definitive r

42、estorative treatment should not be instituted for at least 4 to 6 weeks after the patient has healed.,Splinting(Wire ligation and composite acid-etch splinting)Emergency (pain, swelling, infection, and discomfort)The

43、 emergencies all take priority over other treatment scheduling.,Medical status a systemic condition that would complicate treatment, a medical consultation is necessary.,PHASES II AND III,Phase II surgery permits pocke

44、t elimination / reduction The restoration of normal osseous form ostectomy-osteoplastyosseous surgery combined with grafting procedures,root resectionsmucogingival and gingivectomyperiodontal-endodontic restorative

45、treatmentprovisional splinting.,Maintenance therapyThe specialist may see the patient once a year or every other year for the less involved cases, whereas the generalist maintains the patient in the recall system. Ad

46、vanced cases may be seen alternately at 2- to 4-month intervals.,PROSTHETIC PRESCRIPTIONWaiting for a period of at least 2 months after periodontal surgery.Partial dentures or a fixed prosthesis,ALTERNATIVE TREATMENT P

47、LANS,Alternative treatment plans should be prepared for the patient who elects to forego splinting and surgery when these are indicated.,In this case the patient may be treated through phase I therapy and be placed on a

48、 maintenance schedule. The establishment of an alternative plan generally calls for a rigorous maintenance schedule with scaling and planing performed more frequently than is otherwise usual.,Treatment criteria,Quality

49、of careIn general, periodontal care seeks the following:Removal of known etiologic factorsReduction of all pockets to a minimal depth to facilitate maintenance by the patient and the dental hygienistCreation of a mai

50、ntainable gingival and osseous architecture,Restoration of a functional and esthetic dentitionMaintenance of the resulting health by the patient, doctor, and hygienist,PHILOSOPHY OF TREATMENT,periodontal diseases can b

51、e treated successfully the health of the diseased periodontium can be restored and the teeth maintained.,The therapeutic concept of today includes all forms of therapy, conservative and complex selected and blended for

52、 the successful management of the individual patient.,Therapy must be tailored to the needs, both physical and psychologic, of the patient.,RECORD KEEPINGThe treatment performed should be recorded carefully at each visi

53、t.,ReferralThere are three basic reasons for referral:(1) professional, (2) moral an ethical, and (3) legal.,Professional: Professional referrals are classified as follows:1. Medical:Referral/consultation is indic

54、ated when a patient's medical history discloses significant information that may contribute to or influence the course and outcome of the treatment or when the dentist suspects illness.,2.Dental: Referral/consultati

55、on is indicated when the dentist cannot provide the entire dental therapy the patient needs. When the examination reveals periodontal disease that the generalist cannot or does not wish to treat, referral to a periodon

56、tist is in order. Equally the periodontist is obligated to refer patients for treatment to the general practitioner or other specialists.,3.Moral and ethical:,The specialists or consulting dentists upon completion of th

57、eir care shall return the patient, unless the patient expressly reveals a different preference, to the referring dentist, or if none, to the dentist of record for future care.,The specialists shall be obligated when the

58、re is no referring dentist and upon a completion of their treatment to inform patients when there is a need for further dental care.,Other reasons for referral include:patient relocation, dentist-patient personality c

59、onflict, and dentist's preference.Some dentists do not use specialty, do not use specialty service,CommunicationInforming the patient about the disease condition;a recall-maintenance schedule should be made.,Docu

60、mentationAll communication, written or verbal, must be properly documented on the patient’s chart.Patients have the right of access to their records and may acquire copies of the original documents, not original docume

61、nts.,Summary,It is difficult for the dentist or specialist to possess expert knowledge and skill in all areas of dentistry because of the ever-expanding scope and complexity of dental therapy.,Today's dentist is conf

62、ronted with a wide range of treatment procedures and available alternatives. At all times during the course of treatment, the primary focus is the patient's welfare.,Effective communication and interaction among the