牙周病的治疗(预后、计划)

1、QUESTION？Is my disease fatal?Will I lose my teeth?Will your treatment help me?What can you do to help me? 第第 11 章章 PROGNOSTIC JUDGMENT TREATMENT PLANNING牙周病的预后和计划牙周病的预后和计划PROGNOSISPrognosisForecast预后预后预测预测预预 后后 类类 型型骨吸收骨吸收 病病 因因 依从性依从性 全身病变全身病变极佳极佳无无可消除可消除良好良好无无良好良好轻轻较差较差中中难消除难消除差差明显明显/未控制未控制极差极差重重有

2、全身因素的牙龈炎有全身因素的牙龈炎全身因素控制后可以痊愈全身因素控制后可以痊愈龈炎的预后龈炎的预后单纯性龈炎：良好单纯性龈炎：良好牙周炎的预后牙周炎的预后总预后总预后个别牙预后个别牙预后牙周炎总预后牙周炎总预后对整个牙列预后的评估，内容包括对整个牙列预后的评估，内容包括 牙周炎的类型牙周炎的类型单因素轻中度单因素轻中度CP，疗效易巩固疗效易巩固有全身因素的牙周炎，变化多样有全身因素的牙周炎，变化多样骨破坏的速度、程度、类型骨破坏的速度、程度、类型 局部因素消除情况局部因素消除情况: 菌斑、根分叉问题、咬菌斑、根分叉问题、咬合合牙松动牙松动余留牙的数目、分布；余留牙的数目、分布；患者依从性患者依

3、从性环境与行为因素环境与行为因素全身、遗传、年龄因素全身、遗传、年龄因素牙周炎个别牙预后牙周炎个别牙预后探诊深度、附着水平：探诊深度、附着水平：部位？程度？部位？程度？袋深浅不是决定的因素。袋深浅不是决定的因素。牙槽骨：牙槽骨：破坏部位、程度、根分叉病变；破坏部位、程度、根分叉病变；牙松动度：牙松动度：自限性？进行性牙松动？自限性？进行性牙松动？牙解剖：牙解剖：牙周病治疗计划牙周病治疗计划总体目标总体目标控制菌斑、炎症控制菌斑、炎症合理的牙周组织形态合理的牙周组织形态纠正：牙周袋纠正：牙周袋 龈退缩龈退缩骨缺损骨缺损 牙松动牙松动牙齿及邻接关系牙齿及邻接关系恢复牙周组织功能恢复牙周组织功能合理

4、的咬合关系合理的咬合关系修复失牙修复失牙戒除不良习惯戒除不良习惯维持长期疗效防复发维持长期疗效防复发口腔卫生指导与菌斑控制口腔卫生指导与菌斑控制定期检查定期检查治疗程序治疗程序主要分为四个阶段主要分为四个阶段第一阶段第一阶段病因治疗病因治疗基础治疗基础治疗INITIAL THERAPY消除、控制：消除、控制：致病因素致病因素临床炎症临床炎症包括下列方法：包括下列方法：自我控制菌斑的方法：自我控制菌斑的方法：刷牙方法和习惯；刷牙方法和习惯；牙线和牙签；牙线和牙签；菌斑显示剂检查菌斑显示剂检查漱口剂漱口剂拔除病牙拔除病牙洁治、刮治、根面平洁治、刮治、根面平整术整术药物控制感染药物控制感染咬合调整咬

5、合调整治疗龋齿，矫正不良治疗龋齿，矫正不良修复体和食物嵌塞修复体和食物嵌塞处理牙周处理牙周-牙髓病变牙髓病变1st阶段结束后阶段结束后46周再评估，确认周再评估，确认疗效、依从性、治疗方案疗效、依从性、治疗方案第二个阶段第二个阶段牙周手术治疗牙周手术治疗并非每个患者都要进行并非每个患者都要进行牙周手术目的牙周手术目的清除袋内感染物清除袋内感染物根面平整根面平整治疗牙槽骨缺损治疗牙槽骨缺损纠正龈及膜龈畸形纠正龈及膜龈畸形基础治疗后基础治疗后13月全面评估月全面评估手术的种类手术的种类牙龈切除术牙龈切除术切除肥大增生的牙龈病理性牙周袋翻瓣术翻瓣术牙周骨手术牙周骨手术骨修整术、植骨GTR膜龈手术膜龈

6、手术牙种植术牙种植术第三阶段第三阶段修复治疗阶段修复治疗阶段并非每个患者都要进行2st阶段后阶段后23月进行月进行松牙固定松牙固定义齿修复、正畸义齿修复、正畸第四阶段第四阶段疗效维护期疗效维护期1st阶段后无论是否需要进行阶段后无论是否需要进行2、3阶段治疗即应当开始，内阶段治疗即应当开始，内容包括：容包括：定期复查定期复查 时间：一般时间：一般36个月个月1次。次。 内容：内容：PLI、CI、DI、GI、BOP、PD、附着水平、牙松动度、附着水平、牙松动度、咬合情况、骨高度、密度、咬合情况、骨高度、密度、危险因素：危险因素：吸烟、全身疾病吸烟、全身疾病复治复治根据发现的问题进行新根据发现的问

7、题进行新一轮的治疗与疗效维护一轮的治疗与疗效维护牙周治疗与院内感染牙周治疗与院内感染P163-164自学自学OVERTHANKS牙周治疗与院内感染牙周治疗与院内感染交叉感染交叉感染 是医院内感染是医院内感染(NOSOCOMIAL INFECTION)中的重要内容之一。中的重要内容之一。医院感染的传播途径有：医院感染的传播途径有：直接接触直接接触病损、血液、体液、龈沟液、菌斑等；病损、血液、体液、龈沟液、菌斑等；吸人吸人含致病菌的气雾或飞溅物含致病菌的气雾或飞溅物(如血液、唾液等如血液、唾液等)；间接接触间接接触(污染器械、手、治疗台等传染媒体污染器械、手、治疗台等传染媒体)；手机手机供水管道中

8、的存水返流人口中。供水管道中的存水返流人口中。我国人群中我国人群中HBV携带者约占携带者约占10%，艾滋病、梅毒等也有增多的趋势。艾滋病、梅毒等也有增多的趋势。牙周诊室控制感染牙周诊室控制感染特点及原则特点及原则病史采集及必要的检查病史采集及必要的检查重视询问全身疾病、传染性疾病。重视询问全身疾病、传染性疾病。“一致对待一致对待”原则原则universal precaution即假定每位患者均有血源性传播的感染性疾病，即假定每位患者均有血源性传播的感染性疾病，诊治中一律严格防交叉感染，必要时作有关的诊治中一律严格防交叉感染，必要时作有关的化验检查。化验检查。 治疗器械的消毒治疗器械的消毒 按器

9、械分类、分别用不同的方法消毒。按器械分类、分别用不同的方法消毒。 “双消毒双消毒”：对使用过的器械应实行消毒液：对使用过的器械应实行消毒液浸泡、超声波或手工清洗、清水冲净干燥、高压灭浸泡、超声波或手工清洗、清水冲净干燥、高压灭菌或其他消毒方法。菌或其他消毒方法。大型设备大型设备如综合治疗台表面等，如综合治疗台表面等，可用可靠的消毒剂进行表面擦拭等。可用可靠的消毒剂进行表面擦拭等。 应尽量使用已消毒的一次性用品应尽量使用已消毒的一次性用品(如检查器、吸唾器、注射器等如检查器、吸唾器、注射器等)。一人一机。一人一机。也可也可2%碘酊擦拭手机的各部位，酒精脱碘碘酊擦拭手机的各部位，酒精脱碘2次，次，

10、也可用也可用1%碘附消毒。碘附消毒。保护性屏障保护性屏障口罩、帽子、防护眼镜、面罩、手套、工作服等口罩、帽子、防护眼镜、面罩、手套、工作服等治疗过程中，治疗过程中，污染的手套不得任意触摸周围的物品，污染的手套不得任意触摸周围的物品，治疗结束后治疗结束后应清洗手套上的血污后再摘除手套，书写病历等。应清洗手套上的血污后再摘除手套，书写病历等。尽量使用尽量使用脚控开关来调节治疗椅脚控开关来调节治疗椅照明灯扶手、开关等可用一次性照明灯扶手、开关等可用一次性覆盖物覆盖。覆盖物覆盖。一次性器械及覆盖一次性器械及覆盖物在用毕后应妥善、单独回收，物在用毕后应妥善、单独回收，作必要的销毁。作必要的销毁。减少治疗

11、椅周围空气中的细菌量减少治疗椅周围空气中的细菌量治疗前治疗前1%过氧化氢或过氧化氢或0.12%氯己定液鼓漱氯己定液鼓漱一分钟，减少患者口中的细菌数量、治疗时的一分钟，减少患者口中的细菌数量、治疗时的气雾污染。气雾污染。诊室内应有良好的诊室内应有良好的通风通风。不在诊室内饮水和进食。不在诊室内饮水和进食。治疗台水管系统的消毒、治疗台水管系统的消毒、阻止水回流的装置；阻止水回流的装置；在每位患者治疗结束后，再空放水在每位患者治疗结束后，再空放水30秒；秒；每天开始工作前再冲水一至数分钟。每天开始工作前再冲水一至数分钟。国外建议超声波洁牙机使用单独的净水储国外建议超声波洁牙机使用单独的净水储水器，并

12、每周用水器，并每周用1:10的次氯酸钠液冲储水的次氯酸钠液冲储水系统，随后立即用蒸馏水冲洗。系统，随后立即用蒸馏水冲洗。严格遵守控制医院感染的原则严格遵守控制医院感染的原则，使病原微生物的扩散和环境的污染使病原微生物的扩散和环境的污染降低到最小的程度。降低到最小的程度。保护患者和医务人员的利益安全。保护患者和医务人员的利益安全。Treatment can alter prognosis. Prognosis has different connotations and nuances. The patient has every right to know the answers to the

13、se 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 odds?What are the financial risks? What are the chances that the treatment will be of benefit? Prognosis has three meanings in dentistry.Diagnostic prognos

14、is. What are evaluations of the course 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 skill of the practitioner, what effect will pe

15、riodontal 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 therapeutic or detrimental?What specific needs dictate that it be prescribed? Judgement of the severity depends on ：1. pocket depth, 2

16、. degree of bone loss,3. tooth mobility,4. crown-root ratio.generalized or localizedThe distribution of disease：Inflammatory factors ：Traumatic factors：Individual tooth therapeutic prognosisincludes such factors as ：Percentage of bone loss; Probing depth;Distribution and type of bone lossPresence an

17、d severity of furcation involvementsMobilityCrown-root ratioPulpal involvementTooth position and occlusalStrategic valueFollowing are factors included in overall prognosis:AgeMedical statusIndividual tooth prognoses (distribution and severity)Degree of involvement, duration, and history of the disea

18、se (rate of progression)Patient cooperationEconomic considerationsKnowledge and ability of the dentistEtiologic factorsAccuracy and completeness of the information gathered at the examinationDentists ability to recognize and eliminate or control the factors causing the diseasethe patients ability an

19、d determination in maintaining 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 status of a dentition is knowledge of its past health

20、status. Speed of breakdown under controls or uncontrols The location, shape and depths of the pocketsTooth mobility can be controlled or eliminated, the prognosis is better.The greater the bone loss, the poorer the prognosis. As bone loss exceeds 50%, the prognosis worsens rapidly.The more irregular

21、 the bone loss, the poorer the prognosis. the pattern of bone loss: horizontal, vertical or infrabony defects.the age of the patient and the etiologic factors involved in the patients disease.poorer prognosis: tilted, drifted, or rotated, hygiene difficult, elimination of pockets impairedperiodontal

22、 disease is complicated by active systemic factors and traumatismmorphologic in nature and include the number and distribution of teeth, tooth morphology, furcation involvement.Extent of involvement. Is the furcation partially or totally involved?Status of bone support. If the bone levels are relati

23、vely sound, the effort to save may be justifiable. Root length and crown-root ratio must be consideredAngulation of root spread. 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

24、 and sociologic, financial considerations.OTHER CONSIDERATIONS IN ESTABLISHING PROGNOSISThe 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 functioning unit. In some instancesthe extracti

25、on 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. This will make treatment planning simpler. the characteristics of hopeless periodontally involved teeth:Associated with intractab

26、le pain relieved, massive infection reduced by extractionMobility beyond 3 degreesFurcation involvement with little or no interradicularboneBone loss beyond the apexBone loss to the apex on one side of the toothGeneralized circumferential bone loss to within 3 mm of the apexPocket depth to the apex

27、without pulpal involvementVertical cracks or fracturesInaccessible perforations or accessory canalsNumber and position of remaining teeth precluding prostheticExtreme caries susceptibilityObjectivesof treatmentTreatment goals should be evaluated in every case.Can treatment objectives of a firm non-r

28、etractable gingiva that does not bleed be reached? Can the pocket be eliminated? Will the bone regenerate? Can the tooth be stabilized? 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

29、“no,” alternative treatment, compromise, 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 will change from a qualitative to a quan

30、titative judgment. TREATMENT PLANPresentationPatient consentOrder of treatmentPhase IPhases Il and IIIMaintenance therapyProsthetic prescriptionAlternative treatment plansTreatment criteriaQuality of carePhilosophy of treatmentRecord keepingReferralPresentationPatient consentAfter hearing the presen

31、tation, the patient must decide whether to undergo treatment. PHASE IFirst steps (The 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

32、ow any surgical interventions)Extractions(Teeth with hopeless prognoses)RestorationsUsually periodontal therapy should precede restorative interventions. the restorations should be temporaryThe provisional splinting during the treatment period should be evaluated. Scheduling of restorative treatment

33、 should be done according to the following general rules:Normal patients. (Restorative treatment starts immediately.)Class I (ADA periodontal disease classification)Without occlusal treatment needCaries control and scaling and root planning. including plaque control, may be simultaneous. Definitive

34、restorative treatment should follow completion of 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 restorative treatment should not be

35、 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 emergencies all take priority over other treatment scheduling.Medical status a systemic condition that would complicat

36、e treatment, a medical consultation is necessary.PHASES II AND IIIPhase II surgery permits pocket elimination / reduction The restoration of normal osseous form ostectomy-osteoplastyosseous surgery combined with grafting proceduresroot resectionsmucogingival and gingivectomyperiodontal-endodontic re

37、storative 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. Advanced cases may be seen alternately at 2- to 4-month intervals.PROSTHETIC

38、PRESCRIPTIONWaiting for a period of at least 2 months after periodontal surgery.Partial dentures or a fixed prosthesis ALTERNATIVE TREATMENT PLANSAlternative treatment plans should be prepared for the patient who elects to forego splinting and surgery when these are indicated. In this case the patie

39、nt may be treated through phase I therapy and be placed on a 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 criteriaQuality of careIn general, peri

40、odontal 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 maintainable gingival and osseous architectureRestoration of a functional and esthetic dentitionMaintenance of

41、 the resulting health by the patient, doctor, and hygienistPHILOSOPHY OF TREATMENTperiodontal diseases can be 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

42、 selected and blended for 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 visit. ReferralThere are three basic reasons for referral:(1

43、) professional, (2) moral an ethical, and (3) legal.Professional: Professional referrals are classified as follows:1. Medical:Referral/consultation is indicated when a patients medical history discloses significant information that may contribute to or influence the course and outcome of the treatme

44、nt or when the dentist suspects illness.2.Dental: Referral/consultation 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 periodontist is in order. Equally the periodontist is obligated to refer patients for treatment to the general practit