师姐给大四下预防课件窝沟封闭

窝沟封闭（Pit-and-fissure

sealants）Q.H.

Zhi支清惠窝沟封闭于1967年由CuetoandBuonocore首次报道，今天在牙科被广泛应用和推荐。儿童的点隙窝沟龋流行病学流行率:咬合面龋损占总的龋损的50.9%6~7

years

old12~14

years

old44%65%氟化物防龋对窝沟龋效果不理想窝沟是龋损易发部位咬合面的解剖结构

容易滞留细菌有机塞、食物残渣、菌斑阻塞窝沟点隙，阻止了氟化物的渗透较薄的牙釉质层

对龋病易感窝沟的解剖形态浅而宽，容易清洁深而窄，容易滞留食物残渣和细菌，窝沟的分类V型I

型不易清洁窝沟龋的发展龋损首先发生在侧壁进展至窝沟底部三角形病损进展期预防窝沟龋的历史回顾预防性充填法（Prophylacticodontotomy）制备I类洞，银汞充填窝沟磨除术（Prophylacticodontoplasty）以圆钻磨除深窝沟窝沟封闭（Pit

and

fissure

sealant）窝沟封闭的发展历史第一代:365nm

紫外光固化,操作时间长,效果不理想第二代:Bis-GMA,

化学固化第三代:430~490nm

可见光,方便，效果好3M

Consisesealant第四代:释氟性窝沟封闭剂Pulpdentsealant窝沟封闭适应证萌出少于4年磨牙深的、易滞留、窄的窝沟点隙窝沟有软化和混浊倾向其他牙齿有咬合面或光滑面龋；被封闭牙没有邻面龋患者接受适当的全身性或局部用氟，但仍然龋活跃窝沟封闭非适应证牙齿萌出四年以上，窝沟经常有色素沉着牙齿未完全萌出，有牙龈覆盖除非患者为龋活跃个体，否则前磨牙不作窝沟封闭牙面窝沟浅而宽，自洁作用好患牙有邻面龋，已有咬合面龋洞（需用充填治疗）患者饮用水源不含氟，患者不能配合龋病预防计划封闭剂成分树脂基质Resin

baseBis-GMA稀释剂Thinner

(dicrease

the

viscosity) methyl

methacrylate

(MMA)et

al.引发剂Initiator self-curelight-cure

(430~490nm

visible

light)填料Filling

(increase

the

compressivestrenth,

rigidity

and

abrasive

resistance)颜色Color (easy

to

identify)酸蚀技术1955由Buonocore首先介绍35~38%磷酸恒牙30秒乳牙60

秒有机质含量高 更耐酸酸蚀使光滑的牙釉质表面变得不规则，增加其表面自由能。当液体树脂基质置于不规则的酸蚀表面，树脂通过毛细管作用浸入表面，单体聚合，树脂扣入牙釉质表面。树脂微突的形成是封闭剂-牙釉质粘结的基本机制。酸蚀技术牙釉质酸蚀形成三种微结构形式:釉小柱核心溶解，周围不溶解釉小柱周围溶解，核心完好不典型形态操作步骤牙面清洁Teeth

cleaning酸蚀Acid-etch冲洗吹干Washing

and

evaporation放置封闭剂Sealant

application封闭剂固化Solidify

of

sealants检查Examination操作步骤1.

牙面清洁Teeth

cleaningcleaning

teeth

thoroughlyslow

speed

hand

piece,

mini

dental

brush

orrubbercap,pumice

powderor

dentifrices

withoutfluoride注意:不能使用脂类清洁剂或含填料的磨料必要时去除可疑龋操作步骤2.

酸蚀Acid-etch35%磷酸,2/3

牙尖斜面,恒牙30s,

乳牙60s,注意:轻轻搅拌以保证牙面接触新鲜的酸，不能污染酸蚀面，酸蚀后的白垩色操作步骤3.

冲洗和干燥Washing

and

evaporation彻底冲洗以去除酸及反应产物,以压缩空气或无色酒精干燥注意：不污染酸蚀面,白垩色操作步骤4.

放置封闭剂自凝性Self-cure

sealants:

mixing

for

10s

to

15s,apply

in

45s.光固化Light-cure

sealants:

apply

on

acid-etched

surfaces,fully

penetration

of

sealant

intothe

fissures,enough

thickness

to

provide

enoughcompressive

strenth,

rigidity操作步骤5.

封闭剂的固化Solidify

of

sealants自凝性self-cure

sealants:

1~2

minutes光固化light-cure

sealants:

430~490nm

visiblelight,1mm

distance,

20~40s操作步骤6.

检测及调牙合（必要时）固化情况、粘结、气泡、遗漏点隙、过度封闭、调牙合检查after

3

months,

6

months

or

1

year

interval,脱落重新封闭临床效果临床评价保留率retention

rate=封闭剂保留的牙数/所有检查的牙齿X100%龋降低相对有效率relative

effectiveness

of

decreased

dental

caries=（对照组患龋率-实验组患龋率）/对照组患龋率X100%临床效果Sealants,

by

providing

a

physical

barrier,

inhibitmicroorganisms

and

food

particles

from

collecting

in

pitsand

fissures.

Sealants

are

highly

effective

in

preventingdental

caries

in

pits

and

fissures

of

teeth

when

applied

bytrained

operators.

Sealant

should

be

placed

on

pits

andfissures

of

children’s

and

adolescents’

permanent

teethwhen

it

is

determined

that

the

tooth

or

the

patient

is

at

riskof

developing

caries.

Fissure

sealing

can

be

recommendedas

a

caries

preventive

measure.Judit

S.

Fissuresealing.

Areview,Fogorv

Sz.

2008Aug;101(4):137-46.与临床效果有关的其他因素下颌保留率比上颌高前磨牙保留率比磨牙高大多数脱落发生在前6个月，重新封闭增加了龋病预防效果成功率因牙齿的选择、术者的技巧、工作态度而异系统性评价Systematic

evaluationof

clinical

effectivenessClinical

effectiveness

of

resin

sealants

to

permanent

teethThe

relative

risks

(RR)

to

develop

dental

caries

after

resinsealants

is

0.14,

0.24,

0.30,

and

0.43

at

12,

24,

36,

and48~54

months,

respectively.

Resin

sealants

were

effectivein

caries

prevention.Abovuo-Saloranta,

et

al.

Cochrane

Database

Syst

Rev.1993Systematic

evaluation

of

clinicaleffectivenessClinical

effectiveness

of

resin

sealants

to

permanent

teethThe

relative

caries

risk

reduction

pooled

estimate

of

resin-basedsealants

on

permanent

1st

molars

was

33%

(relative

risk

=

0.67;CI

=

0.55-0.83).

The

effect

depended

on

retention

of

thesealant.

In

conclusion,

the

review

suggests

limited

evidence

thatfissure

sealing

of

1st

permanent

molars

with

resin-basedmaterials

has

a

caries-preventive

effect.

The

evidence

isincomplete

for

permanent

2nd

molars,

premolars

and

primarymolars

and

for

glass

ionomer

cements.Mejare

I,

et

al.

Caries-preventive

effect

of

fissure

sealants:

asystematic

review.

Acta

Odontol

Scand.

2003

Dec;61(6):321-30.Systematic

evaluation

of

clinicaleffectivenessClinical

effectiveness

of

resin

sealants

to

permanent

teethResin

sealants

are

effective

in

preventing

dental

caries

onocclusal

surfaces

of

permanent

teeth.The

evidence

is

incomplete

for

primary

teeth.Systematic

evaluation

of

clinicaleffectivenessClinical

effectiveness

of

glass

ionomer

(GIC)

sealantsOnly

one

parallel

study

used

GIC

sealants.

No

statistic

difference

wasfound

after

24

months.

The

retention

rates

of

different

GIC

weredifferent

and

the

evidence

was

incomplete.

Better

designed

studieswere

needed

to

prove

the

preventive

effect

of

GIC

sealants.Abovuo-Saloranta,

et

al.

Cochrane

Database

Syst

Rev.

1993Systematic

evaluation

of

clinicaleffectivenessComparision

between

self-cure

and

light-cure

sealantsno

significant

difference

between

them

regarding

theretention

rate

and

the

preventive

effectComparision

between

sealants

with

and

without

fluorideno

significant

difference

between

them

regarding

theretention

rate

and

the

preventive

effectComparision

between

GIC

and

resin

sealantsincomplete

evidence

to

show

there’s

a

differenceSystematic

evaluation

of

clinicaleffectivenessThe

accepted

reviews

provided

no

evidence

of

superiority

ofeither

sealant

material.

Six

trials

were

included

for

meta-analysis.

The

pooled

odds

ratio

was

0.96,

95%

CI

0.62-1.49,indicating

no

difference

in

the

caries-preventive

effect

of

GIC

and

resin-based

fissure

sealant

material.

This

systematic

reviewwith

meta-analysis

found

no

evidence

that

either

material

wassuperior

to

the

other

in

the

prevention

of

dental

caries.

Thus,bothmaterialsappearequallysuitablefor

clinicalapplicationasa

fissure

sealant

material.Yengopal

V,

Mickenautsch

S,

Bezerra

AC,

Leal

SC.Caries-preventive

effect

of

glass

ionomer

and

resin-basedfissuresealants

on

permanent

teeth:

a

meta

analysis.

J

Oral

Sci.

2009Sep;51(3):373-82.Systematic

evaluation

of

clinicaleffectivenessPit

and

fissure

sealants

for

preventing

dental

decay

in

thepermanentteeth

of

childrenandadolescents.Ahovuo-Salorant

A,

Cochrane

Database

Syst

Rev.

2008

Oct8;(4):CD001830.OBJECTIVES:The

primary

objective

of

this

review

was

to

evaluate

thecaries

prevention

of

pit

and

fissure

sealants

in

children

andadolescents.Systematic

evaluation

of

clinicaleffectivenessMAINRESULTS:Sixteen

studies

were

included

in

the

review;

7

studies

provided

datafor

comparison

of

sealant

versus

control

without

sealant

and

10studies

for

comparison

of

sealant

versussealant.Systematic

evaluation

of

clinicaleffectivenessMAINRESULTS:Five

split-mouth

studies

and

one

parallelgroup

study

with

5

to

10

yearold

children

found

a

significant

difference

in

favour

of

second

or

thirdgeneration

resin-based

sealants

on

first

permanent

molars,

comparedto

a

control

without

sealant,

witha

pooled

RRof

0.13

(95%

confidenceinterval

(CI)

0.09

to

0.20),

0.22

(95%

CI

0.15

to

0.34),

0.30

(95%CI0.22

to

0.40),

and

0.40

(95%

CI

0.31

to

0.51)

at

12,

24,

36

and

48-54months

followup,

respectively.

Further,

one

of

those

studies

with9years

of

follow

up

found

significantly

more

caries

in

the

control

groupcompared

to

resin

sealant

group;

27%

of

sealed

surfaces

weredecayed

compared

to

77%

of

surfaces

without

sealant.The

results

ofthe

studies

comparing

different

sealant

materials

wereconflicting.Systematic

evaluation

of

clinicaleffectivenessAUTHORS'

CONCLUSIONS:Sealing

is

a

recommended

procedure

to

prevent

caries

ofthe

occlusal

surfaces

of

permanent

molars.

Theeffectiveness

of

sealants

is

obvious

at

high

caries

risk

butinformation

on

the

benefits

of

sealing

specific

to

differentcaries

risks

is

lacking.影响窝沟封闭预防效果的因素窝沟封闭对预防龋病是有效的自凝性封闭剂比光固化的更有效封闭剂的预防效果随时间递减封闭剂和加氟联合预防效果更好Liodra

JC,

et

al.

Factors

influencing

the

effectiveness

of

sealants-ameta-analysis,

Community

Dent

Oral

Epidermal

1993,21:261-8窝沟封闭的其他问题酸蚀后牙面的龋易感性即使封闭剂脱落，酸蚀后牙面在酸性溶液中的溶解度与未酸蚀牙面相近酸蚀后牙面唾液污染唾液污染阻止了树脂微突的形成，造成封闭剂脱落、细菌侵入，引起龋齿以压缩空气、橡皮障或棉卷隔湿唾液污染后重新酸蚀窝沟封闭的其他问题早期窝沟龋的封闭酸蚀

杀死窝沟中的微生物封闭剂

阻止细菌的营养供应酸蚀后少于3%细菌存活在窝沟封闭后早期龋停止进展封闭性充填Sealant

restorationThe

sealant

restoration

is

indicated

primarily

on

theocclusal

surfaces

of

permanent

molars

and

premolars

andmay

also

be

indicated

for

primary

molars.

They

are

mostappropriate

when

the

prepared

cavity

in

a

pit

or

fissure

issmall

and

discrete.

Larger

cavities

wou