牙周病的治療預后計劃培訓課件

1、第 11 章 PROGNOSTIC JUDGMENT TREATMENT PLANNING牙周病的預后和計劃第 11 章 PROGNOSTIC JUDGMENT TRPROGNOSISPrognosisForecast預后預測PROGNOSISPrognosisForecast預預 后 類 型骨吸收病 因依從性全身病變極佳無可消除良好無良好輕較差中難消除差明顯/未控制極差重預 后 類 型骨吸收病 因依從性全身病變極佳無可消除良好無整體預后依據(jù)病史、年齡疾病類型 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 解剖牙周破壞程度整體預后依據(jù)病史、年齡疾病類型 發(fā)展速度全身因素 環(huán)境因素有全

2、身因素的牙齦炎全身因素控制后可以痊愈齦炎的預后單純性齦炎：良好有全身因素的牙齦炎全身因素控制后可以痊愈齦炎的預后單純性牙周炎的預后總預后個別牙預后牙周炎的預后總預后牙周炎總預后對整個牙列預后的評估，內容包括 牙周炎的類型單因素輕中度CP，療效易鞏固有全身因素的牙周炎，變化多樣牙周炎總預后對整個牙列預后的評估，內容包括 牙周炎的類型骨破壞的速度、程度、類型 局部因素消除情況: 菌斑、根分叉問題、咬合牙松動余留牙的數(shù)目、分布；患者依從性環(huán)境與行為因素全身、遺傳、年齡因素骨破壞的速度、程度、類型 局部因素消除情況:牙周炎個別牙預后探診深度、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

3、、程度、根分叉病變；牙松動度：自限性？進行性牙松動？牙解剖：牙周炎個別牙預后探診深度、附著水平：牙周病治療計劃牙周病治療計劃總體目標控制菌斑、炎癥合理的牙周組織形態(tài)糾正：牙周袋 齦退縮骨缺損 牙松動牙齒及鄰接關系總體目標控制菌斑、炎癥恢復牙周組織功能合理的咬合關系修復失牙戒除不良習慣維持長期療效防復發(fā)口腔衛(wèi)生指導與菌斑控制定期檢查恢復牙周組織功能合理的咬合關系修復失牙戒除不良習慣維持治療程序主要分為四個階段治療程序主要分為四個階段第一階段病因治療基礎治療INITIAL THERAPY消除、控制：致病因素臨床炎癥第一階段病因治療基礎治療包括下列方法：自我控制菌斑的方法：刷牙方法和習慣；牙線和牙簽

4、；菌斑顯示劑檢查漱口劑包括下列方法：自我控制菌斑的方法：拔除病牙潔治、刮治、根面平整術藥物控制感染咬合調整拔除病牙潔治、刮治、根面平整術治療齲齒，矯正不良修復體和食物嵌塞處理牙周-牙髓病變1st階段結束后46周再評估，確認療效、依從性、治療方案治療齲齒，矯正不良修復體和食物嵌塞處理牙周-牙髓病變1st階第二個階段牙周手術治療并非每個患者都要進行第二個階段牙周手術治療牙周手術目的清除袋內感染物根面平整治療牙槽骨缺損糾正齦及膜齦畸形基礎治療后13月全面評估牙周手術目的清除袋內感染物根面平整治療牙槽骨缺損手術的種類牙齦切除術切除肥大增生的牙齦病理性牙周袋手術的種類牙齦切除術翻瓣術牙周骨手術骨修整術、

5、植骨GTR膜齦手術牙種植術翻瓣術牙周骨手術第三階段修復治療階段并非每個患者都要進行2st階段后23月進行松牙固定義齒修復、正畸第三階段修復治療階段并非每個患者都要進行2st階段后2第四階段療效維護期1st階段后無論是否需要進行2、3階段治療即應當開始，內容包括：第四階段療效維護期1st階段后無論是否需要進行2、3階段治定期復查 時間：一般36個月1次。 內容：PLI、CI、DI、GI、BOP、PD、附著水平、牙松動度、咬合情況、骨高度、密度、危險因素：吸煙、全身疾病定期復查 時間：一般36個月1次。復治根據(jù)發(fā)現(xiàn)的問題進行新一輪的治療與療效維護復治根據(jù)發(fā)現(xiàn)的問題進行新一輪的治療與療效維護牙周治療

6、與院內感染P163-164自學牙周治療與院內感染P163-164自學OVERTHANKSOVERTHANKS牙周治療與院內感染交叉感染 是醫(yī)院內感染(NOSOCOMIAL INFECTION)中的重要內容之一。牙周治療與院內感染交叉感染 是醫(yī)院內感染(NOSOCO醫(yī)院感染的傳播途徑有：直接接觸病損、血液、體液、齦溝液、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、治療臺等傳染媒體)；手機供水管道中的存水返流人口中。醫(yī)院感染的傳播途徑有：直接接觸病損、血液、體液、齦溝液、菌斑我國人群中HBV攜帶者約占10%，艾滋病、梅毒等也有增多的趨勢。我國人群中HBV攜帶者約占

7、10%，艾滋病、梅毒等也有增多的牙周診室控制感染特點及原則牙周診室控制感染特點及原則病史采集及必要的檢查重視詢問全身疾病、傳染性疾病。“一致對待”原則universal precaution即假定每位患者均有血源性傳播的感染性疾病，診治中一律嚴格防交叉感染，必要時作有關的化驗檢查。病史采集及必要的檢查重視詢問全身疾病、傳染性疾病?！耙?治療器械的消毒 按器械分類、分別用不同的方法消毒。 “雙消毒”：對使用過的器械應實行消毒液浸泡、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。大型設備如綜合治療臺表面等，可用可靠的消毒劑進行表面擦拭等。 治療器械的消毒 按器械分類、分別用不同的方法消毒

8、。應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。也可2%碘酊擦拭手機的各部位，酒精脫碘2次，也可用1%碘附消毒。應盡量使用已消毒的一次性用品(如檢查器、吸唾器、注射器等)保護性屏障口罩、帽子、防護眼鏡、面罩、手套、工作服等治療過程中，污染的手套不得任意觸摸周圍的物品，治療結束后應清洗手套上的血污后再摘除手套，書寫病歷等。保護性屏障口罩、帽子、防護眼鏡、面罩、手套、工作服等治療盡量使用腳控開關來調節(jié)治療椅照明燈扶手、開關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妥善、單獨回收，作必要的銷毀。盡量使用腳控開關來調節(jié)治療椅照明燈扶手、開關等可用一次性覆減少治療椅周圍

9、空氣中的細菌量治療前1%過氧化氫或0.12%氯己定液鼓漱一分鐘，減少患者口中的細菌數(shù)量、治療時的氣霧污染。診室內應有良好的通風。不在診室內飲水和進食。減少治療椅周圍空氣中的細菌量治療前1%過氧化氫或0.12%治療臺水管系統(tǒng)的消毒、阻止水回流的裝置；在每位患者治療結束后，再空放水30秒；每天開始工作前再沖水一至數(shù)分鐘。國外建議超聲波潔牙機使用單獨的凈水儲水器，并每周用1:10的次氯酸鈉液沖儲水系統(tǒng)，隨后立即用蒸餾水沖洗。治療臺水管系統(tǒng)的消毒、阻止水回流的裝置；在每位患者治療結嚴格遵守控制醫(yī)院感染的原則，使病原微生物的擴散和環(huán)境的污染降低到最小的程度。保護患者和醫(yī)務人員的利益安全。嚴格遵守控制醫(yī)院

10、感染的原則，使病原微生物的擴散和環(huán)境的污染Treatment can alter prognosis. Prognosis has different connotations and nuances. The patient has every right to know the answers to these questions. Treatment can alter prognosis.Question？Is my disease fatal?Will I lose my teeth?Will your treatment help me?What can you do to hel

11、p me? Question？Is my disease fatal?What are the therapeutic odds?What are the financial risks? What are the chances that the treatment will be of benefit? What are the therapeutic oddsPrognosis has three meanings in dentistry.Prognosis has three meaningsDiagnostic prognosis. What are evaluations of

12、the course of the disease without treatment? What is the status of the teeth nowWhat is the anticipated future of these teeth?Diagnostic prognosis. What areTherapeutic prognosis. Given the state of the art and science of periodontics and the knowledge and skill of the practitioner, what effect will

13、periodontal treatment have on the course of the disease?Therapeutic prognosis. Given tProsthetic 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? Prosthetic prognosis. Wh

14、at is Judgement of the severity depends on ：1. pocket depth, 2. degree of bone loss,3. tooth mobility,4. crown-root ratio.Judgement of the severity depegeneralized or localizedThe distribution of disease：Inflammatory factors ：Traumatic factors：generalized or localizedThe diIndividual tooth therapeut

15、ic prognosisincludes such factors as ：Percentage of bone loss; Probing depth;Individual tooth therapeutic pDistribution and type of bone lossPresence and severity of furcation involvementsMobilityDistribution and type of bone Crown-root ratioPulpal involvementTooth position and occlusalStrategic val

16、ueCrown-root ratioPulpal involvFollowing are factors included in overall prognosis:AgeMedical statusFollowing are factors includedIndividual tooth prognoses (distribution and severity)Degree of involvement, duration, and history of the disease (rate of progression)Individual tooth prognoses (Patient

17、 cooperationEconomic considerationsKnowledge and ability of the dentistEtiologic factorsPatient cooperationEconomic cAccuracy and completeness of the information gathered at the examinationDentists ability to recognize and eliminate or control the factors causing the diseaseAccuracy and completeness

18、 of tthe patients ability and determination in maintaining the health of the periodontium and teeth.the patients ability and deteThe overall prognosis depends on the prognoses of the individual teeth. The overall prognosis depends PAST HISTORY (RATE OF DESTRUCTION)PAST HISTORY (RATE OF DESTRUCProbab

19、ly the most important factor in forecasting the future health status of a dentition is knowledge of its past health status. Probably the most important faSpeed of breakdown under controls or uncontrols The location, shape and depths of the pocketsSpeed of breakdown under contrTooth mobility can be c

20、ontrolled or eliminated, the prognosis is better.The greater the bone loss, the poorer the prognosis. Tooth mobility can be controllAs bone loss exceeds 50%, the prognosis worsens rapidly.The more irregular the bone loss, the poorer the prognosis. As bone loss exceeds 50%, the the pattern of bone lo

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

22、ase is complicated by active systemic factors and traumatismperiodontal disease is complicmorphologic in nature and include the number and distribution of teeth, tooth morphology, furcation involvement.morphologic in nature and inclExtent of involvement. Is the furcation partially or totally involve

23、d?Status of bone support. If the bone levels are relatively sound, the effort to save may be justifiable. Extent of involvement. Is theRoot length and crown-root ratio must be consideredRoot length and crown-root ratAngulation of root spread. Health of neighboring teeth. Angulation of root spread. H

24、eThe number and distribution of teeth presentcrown-root ratio,shape and number of the root The number and distribution ofthe height of the alveolar crestpersonal psychologic and sociologic, financial considerations.the height of the alveolar creOTHER CONSIDERATIONS IN ESTABLISHING PROGNOSISOTHER CON

25、SIDERATIONS IN ESTABLThe performance of home care is acceptable and the caries incidence is low,the prognosis is better The performance of home care iThe prime consideration is the preservation of the dentition as a functioning unit. The prime consideration is theIn some instancesthe extraction of a

26、 single tooth will make the whole situation untenable.In other situations isolated extractions will simplify the problem.In some instancesthe extractiwhat is considered to be a hopeless tooth. This will make treatment planning simpler. what is considered to be a hopthe characteristics of hopeless pe

27、riodontally involved teeth:the characteristics of hopelesAssociated with intractable pain relieved, massive infection reduced by extractionMobility beyond 3 degreesAssociated with intractable paFurcation involvement with little or no interradicularboneBone loss beyond the apexBone loss to the apex o

28、n one side of the toothFurcation involvement with litGeneralized circumferential bone loss to within 3 mm of the apexPocket depth to the apex without pulpal involvementVertical cracks or fracturesGeneralized circumferential boInaccessible perforations or accessory canalsNumber and position of remain

29、ing teeth precluding prostheticExtreme caries susceptibilityInaccessible perforations or aObjectivesof treatmentObjectivesof treatmentTreatment goals should be evaluated in every case.Treatment goals should be evalCan treatment objectives of a firm non-retractable gingiva that does not bleed be reac

30、hed? Can the pocket be eliminated? Will the bone regenerate? Can the tooth be stabilized? Can treatment objectives of a Can tooth be restored?Can the patient tolerate the treatment? Can tooth be restored?Can theIf you believe the answers to these questions to be yes, then plan and proceed with the t

31、reatment. If “no,” alternative treatment, compromise, or extraction is advisable.If you believe the answers to 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, prognos

32、is will change from a qualitative to a quantitative judgment. As definitive laboratory testsTREATMENT PLANTREATMENT PLANPresentationPatient consentOrder of treatmentPhase IPhases Il and IIIMaintenance therapyProsthetic prescriptionPresentationPatient consentOAlternative treatment plansTreatment crit

33、eriaQuality of carePhilosophy of treatmentRecord keepingReferralAlternative treatment plansTrPresentationPatient consentAfter hearing the presentation, the patient must decide whether to undergo treatment. PresentationPatient consentAPHASE IPHASE IFirst steps (The initial effort) should be directed

34、toward the elimination of inflammation and the institution of a program of plaque control. First steps (The initial efforTo reduce pocket depthTo minimize periodontal traumatismOrthodontics(may precede or follow any surgical interventions)To reduce pocket depthTo miniExtractions(Teeth with hopeless

35、prognoses)RestorationsUsually periodontal therapy should precede restorative interventions. the restorations should be temporaryExtractions(Teeth with hopeleThe provisional splinting during the treatment period should be evaluated. The provisional splinting durScheduling of restorative treatment sho

36、uld be done according to the following general rules:Scheduling of restorative treaNormal patients. (Restorative treatment starts immediately.)Class I (ADA periodontal disease classification)Normal patients. (Restorative Without occlusal treatment needCaries control and scaling and root planning. in

37、cluding plaque control, may be simultaneous. Definitive restorative treatment should follow completion of scaling and plaque control.Without occlusal treatment neeWith occlusal treatment need Definitive restorative treatment may immediately follow completion of scaling, plaque control, and occlusal

38、adjustment.With occlusal treatment need DWith surgical treatment need Definitive restorative treatment should not be instituted for at least 4 to 6 weeks after the patient has healed.With surgical treatment need DSplinting(Wire ligation and composite acid-etch splinting)Emergency (pain, swelling, in

39、fection, and discomfort)The emergencies all take priority over other treatment scheduling.Splinting(Wire ligation and cMedical status a systemic condition that would complicate treatment, a medical consultation is necessary.Medical status a systemic conPHASES II AND IIIPHASES II AND IIIPhase II surg

40、ery permits pocket elimination / reduction The restoration of normal osseous form ostectomy-osteoplastyosseous surgery combined with grafting proceduresPhase II surgery permits pockroot resectionsmucogingival and gingivectomyperiodontal-endodontic restorative treatmentprovisional splinting.root rese

41、ctionsmucogingival aMaintenance 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.Maintenance therapyThe speciaPRO

42、STHETIC PRESCRIPTIONWaiting for a period of at least 2 months after periodontal surgery.Partial dentures or a fixed prosthesis PROSTHETIC PRESCRIPTIONWaitinALTERNATIVE TREATMENT PLANSALTERNATIVE TREATMENT PLANSAlternative treatment plans should be prepared for the patient who elects to forego splint

43、ing and surgery when these are indicated. Alternative treatment plans sIn this case the patient 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 perfor

44、med more frequently than is otherwise usual.In this case the patient may bTreatment criteriaTreatment criteriaQuality 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

45、 dental hygienistCreation of a maintainable gingival and osseous architectureQuality of careIn general, peRestoration of a functional and esthetic dentitionMaintenance of the resulting health by the patient, doctor, and hygienistRestoration of a functional anPHILOSOPHY OF TREATMENTPHILOSOPHY OF TREA

46、TMENTperiodontal diseases can be treated successfully the health of the diseased periodontium can be restored and the teeth maintained.periodontal diseases can be trThe therapeutic concept of today includes all forms of therapy, conservative and complex selected and blended for the successful manage

47、ment of the individual patient. The therapeutic concept of todTherapy must be tailored to the needs, both physical and psychologic, of the patient. Therapy must be tailored to thRECORD KEEPINGThe treatment performed should be recorded carefully at each visit. RECORD KEEPINGThe treatment pReferralThe

48、re are three basic reasons for referral:(1) professional, (2) moral an ethical, and (3) legal.ReferralThere are three basicProfessional: Professional referrals are classified as follows:1. Medical:Referral/consultation is indicated when a patients medical history discloses significant information th

49、at may contribute to or influence the course and outcome of the treatment or when the dentist suspects illness.Professional: Professional re2.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 practitioner or other specialists.2.Dental: Referral/consultati3.Moral and ethical: The speci