牙周病的預(yù)后和計(jì)劃專家講座

QUESTION？Ismydiseasefatal?

WillIlosemyteeth?

Willyourtreatmenthelpme?

Whatcanyoudotohelpme?牙周病的預(yù)后和計(jì)劃第1頁第11章

PROGNOSTICJUDGMENTTREATMENTPLANNING牙周病預(yù)后和計(jì)劃牙周病的預(yù)后和計(jì)劃第2頁P(yáng)ROGNOSISPrognosisForecast

預(yù)后預(yù)測(cè)牙周病的預(yù)后和計(jì)劃第3頁預(yù)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顯著/未控制極差重牙周病的預(yù)后和計(jì)劃第4頁整體預(yù)后依據(jù)病史、年紀(jì)疾病類型發(fā)展速度全身原因環(huán)境原因患者意愿、依從性菌斑牙石量解剖牙周破壞程度牙周病的預(yù)后和計(jì)劃第5頁有全身原因牙齦炎

全身原因控制后能夠痊愈齦炎預(yù)后

單純性齦炎：良好牙周病的預(yù)后和計(jì)劃第6頁牙周炎預(yù)后總預(yù)后個(gè)別牙預(yù)后牙周病的預(yù)后和計(jì)劃第7頁牙周炎總預(yù)后

對(duì)整個(gè)牙列預(yù)后評(píng)定，內(nèi)容包含牙周炎類型單原因輕中度CP，療效易鞏固有全身原因牙周炎，改變多樣牙周病的預(yù)后和計(jì)劃第8頁骨破壞速度、程度、類型局部原因消除情況:菌斑、根分叉問題、咬合牙松動(dòng)余留牙數(shù)目、分布；患者依從性環(huán)境與行為原因全身、遺傳、年紀(jì)原因牙周病的預(yù)后和計(jì)劃第9頁牙周炎個(gè)別牙預(yù)后探診深度、附著水平：部位？程度？袋深淺不是決定原因。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：牙周病的預(yù)后和計(jì)劃第10頁牙周病治療計(jì)劃牙周病的預(yù)后和計(jì)劃第11頁總體目標(biāo)控制菌斑、炎癥合理牙周組織形態(tài)糾正：牙周袋齦退縮骨缺損牙松動(dòng)牙齒及鄰接關(guān)系牙周病的預(yù)后和計(jì)劃第12頁恢復(fù)牙周組織功效

合理咬合關(guān)系

修復(fù)失牙

戒除不良習(xí)慣維持長久療效防復(fù)發(fā)口腔衛(wèi)生指導(dǎo)與菌斑控制定時(shí)檢驗(yàn)牙周病的預(yù)后和計(jì)劃第13頁治療程序主要分為四個(gè)階段牙周病的預(yù)后和計(jì)劃第14頁第一階段

病因治療基礎(chǔ)治療INITIALTHERAPY消除、控制：致病原因臨床炎癥牙周病的預(yù)后和計(jì)劃第15頁包含以下方法：自我控制菌斑方法：刷牙方法和習(xí)慣；牙線和牙簽；菌斑顯示劑檢驗(yàn)漱口劑牙周病的預(yù)后和計(jì)劃第16頁拔除病牙潔治、刮治、根面平整術(shù)藥品控制感染咬合調(diào)整牙周病的預(yù)后和計(jì)劃第17頁治療齲齒，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)定，確認(rèn)療效、依從性、治療方案牙周病的預(yù)后和計(jì)劃第18頁第二個(gè)階段牙周手術(shù)治療并非每個(gè)患者都要進(jìn)行牙周病的預(yù)后和計(jì)劃第19頁牙周手術(shù)目標(biāo)去除袋內(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月全方面評(píng)定牙周病的預(yù)后和計(jì)劃第20頁手術(shù)種類牙齦切除術(shù)切除肥大增生牙齦病理性牙周袋牙周病的預(yù)后和計(jì)劃第21頁翻瓣術(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)牙周病的預(yù)后和計(jì)劃第22頁第三階段

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)、正畸牙周病的預(yù)后和計(jì)劃第23頁第四階段

療效維護(hù)期1st階段后不論是否需要進(jìn)行2、3階段治療即應(yīng)該開始，內(nèi)容包含：牙周病的預(yù)后和計(jì)劃第24頁定時(shí)復(fù)查時(shí)間：普通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)原因：吸煙、全身疾病牙周病的預(yù)后和計(jì)劃第25頁復(fù)治依據(jù)發(fā)覺問題進(jìn)行新一輪治療與療效維護(hù)牙周病的預(yù)后和計(jì)劃第26頁牙周治療與院內(nèi)感染

P163-164自學(xué)牙周病的預(yù)后和計(jì)劃第27頁OVER

THANKS牙周病的預(yù)后和計(jì)劃第28頁牙周治療與院內(nèi)感染

交叉感染是醫(yī)院內(nèi)感染(NOSOCOMIALINFECTION)中主要內(nèi)容之一。牙周病的預(yù)后和計(jì)劃第29頁醫(yī)院感染傳輸路徑有：直接接觸病損、血液、體液、齦溝液、菌斑等；吸人含致病菌氣霧或飛濺物(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)供水管道中存水返流人口中。牙周病的預(yù)后和計(jì)劃第30頁我國人群中HBV攜帶者約占10%，

艾滋病、梅毒等也有增多趨勢(shì)。牙周病的預(yù)后和計(jì)劃第31頁牙周診室控制感染

特點(diǎn)及標(biāo)準(zhǔn)牙周病的預(yù)后和計(jì)劃第32頁病史采集及必要檢驗(yàn)

重視問詢?nèi)砑膊?、傳染性疾病?/p>

“一致對(duì)待”標(biāo)準(zhǔn)

universalprecaution

即假定每位患者都有血源性傳輸感染性疾病，診治中一律嚴(yán)格防交叉感染，必要時(shí)作相關(guān)化驗(yàn)檢驗(yàn)。牙周病的預(yù)后和計(jì)劃第33頁治療器械消毒

按器械分類、分別用不一樣方法消毒。

“雙消毒”：對(duì)使用過器械應(yīng)實(shí)施消毒液浸泡、超聲波或手工清洗、清水沖凈干燥、高壓滅菌或其它消毒方法。

大型設(shè)備如綜合治療臺(tái)表面等，

可用可靠消毒劑進(jìn)行表面擦拭等。牙周病的預(yù)后和計(jì)劃第34頁應(yīng)盡可能使用已消毒一次性用具

(如檢驗(yàn)器、吸唾器、注射器等)。

一人一機(jī)。

也可2%碘酊擦拭手機(jī)各部位，酒精脫碘2次，

也可用1%碘附消毒。牙周病的預(yù)后和計(jì)劃第35頁保護(hù)性屏障

口罩、帽子、防護(hù)眼鏡、面罩、手套、工作服等

治療過程中，

污染手套不得任意觸摸周圍物品，

治療結(jié)束后

應(yīng)清洗手套上血污后再摘除手套，書寫病歷等。牙周病的預(yù)后和計(jì)劃第36頁盡可能使用腳控開關(guān)來調(diào)整治療椅

照明燈扶手、開關(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，作必要銷毀。牙周病的預(yù)后和計(jì)劃第37頁降低治療椅周圍空氣中細(xì)菌量

治療前1%過氧化氫或0.12%氯己定液鼓漱一分鐘，降低患者口中細(xì)菌數(shù)量、治療時(shí)氣霧污染。

診室內(nèi)應(yīng)有良好通風(fēng)。

不在診室內(nèi)飲水和進(jìn)食。牙周病的預(yù)后和計(jì)劃第38頁治療臺(tái)水管系統(tǒng)消毒、

阻止水回流裝置；

在每位患者治療結(jié)束后，再空放水30秒；

天天開始工作前再?zèng)_水一至數(shù)分鐘。

國外提議超聲波潔牙機(jī)使用單獨(dú)凈水儲(chǔ)水器，并每七天用1:10次氯酸鈉液沖儲(chǔ)水系統(tǒng)，隨即馬上用蒸餾水沖洗。牙周病的預(yù)后和計(jì)劃第39頁嚴(yán)格恪守控制醫(yī)院感染標(biāo)準(zhǔn)，

使病原微生物擴(kuò)散和環(huán)境污染降低到最小程度。

保護(hù)患者和醫(yī)務(wù)人員利益安全。牙周病的預(yù)后和計(jì)劃第40頁Treatmentcanalterprognosis.Prognosishasdifferentconnotationsandnuances.Thepatienthaseveryrighttoknowtheanswerstothesequestions.牙周病的預(yù)后和計(jì)劃第41頁Question？Ismydiseasefatal?

WillIlosemyteeth?

Willyourtreatmenthelpme?

Whatcanyoudotohelpme?牙周病的預(yù)后和計(jì)劃第42頁Whatarethetherapeutic"odds"?

Whatarethefinancialrisks?

Whatarethechancesthatthetreatmentwillbeofbenefit?牙周病的預(yù)后和計(jì)劃第43頁P(yáng)rognosishas

threemeanings

indentistry.牙周病的預(yù)后和計(jì)劃第44頁Diagnosticprognosis.Whatareevaluationsofthecourseofthediseasewithouttreatment?WhatisthestatusoftheteethnowWhatistheanticipatedfutureoftheseteeth?牙周病的預(yù)后和計(jì)劃第45頁Therapeuticprognosis.Giventhestateoftheartandscienceofperiodonticsandtheknowledgeandskillofthepractitioner,whateffectwillperiodontaltreatmenthaveonthecourseofthedisease?牙周病的預(yù)后和計(jì)劃第46頁P(yáng)rostheticprognosis.Whatistheforecastforthesuccessoftheprostheticrestoration?Willtheprosthesisbetherapeuticordetrimental?Whatspecificneedsdictatethatitbeprescribed?牙周病的預(yù)后和計(jì)劃第47頁Judgementoftheseveritydependson：1.pocketdepth,2.degreeofboneloss,3.toothmobility,4.crown-rootratio.牙周病的預(yù)后和計(jì)劃第48頁generalizedorlocalizedThedistributionofdisease：Inflammatoryfactors：Traumaticfactors：牙周病的預(yù)后和計(jì)劃第49頁Individualtooththerapeuticprognosisincludessuchfactorsas：Percentageofboneloss;Probingdepth;牙周病的預(yù)后和計(jì)劃第50頁Distributionandtype

ofboneloss

Presenceandseverityof

furcationinvolvements

Mobility牙周病的預(yù)后和計(jì)劃第51頁Crown-rootratio

Pulpalinvolvement

Toothpositionandocclusal

Strategicvalue牙周病的預(yù)后和計(jì)劃第52頁Followingarefactorsincludedinoverallprognosis:AgeMedicalstatus牙周病的預(yù)后和計(jì)劃第53頁Individualtoothprognoses

(distributionandseverity)

Degreeofinvolvement,duration,andhistory

ofthedisease(rateofprogression)牙周病的預(yù)后和計(jì)劃第54頁P(yáng)atientcooperation

Economicconsiderations

Knowledgeandabilityofthedentist

Etiologicfactors牙周病的預(yù)后和計(jì)劃第55頁Accuracyandcompletenessoftheinformationgatheredattheexamination

Dentist'sabilitytorecognizeandeliminateorcontrolthefactorscausingthedisease牙周病的預(yù)后和計(jì)劃第56頁thepatient'sabilityanddeterminationinmaintainingthehealthoftheperiodontiumandteeth.牙周病的預(yù)后和計(jì)劃第57頁Theoverallprognosisdependsontheprognosesoftheindividualteeth.牙周病的預(yù)后和計(jì)劃第58頁P(yáng)ASTHISTORY

(RATEOFDESTRUCTION)牙周病的預(yù)后和計(jì)劃第59頁P(yáng)robablythemostimportantfactorinforecastingthefuturehealthstatusofadentitionisknowledgeofitspasthealthstatus.

牙周病的預(yù)后和計(jì)劃第60頁Speedofbreakdownundercontrolsoruncontrols

Thelocation,shapeanddepthsofthepockets牙周病的預(yù)后和計(jì)劃第61頁Toothmobilitycanbecontrolledoreliminated,theprognosisisbetter.

Thegreatertheboneloss,thepoorertheprognosis.牙周病的預(yù)后和計(jì)劃第62頁Asbonelossexceeds50%,theprognosisworsensrapidly.

Themoreirregulartheboneloss,thepoorertheprognosis.牙周病的預(yù)后和計(jì)劃第63頁thepatternofboneloss:horizontal,verticalorinfrabonydefects.

theageofthepatientandtheetiologicfactorsinvolvedinthepatient'sdisease.牙周病的預(yù)后和計(jì)劃第64頁poorerprognosis:

tilted,drifted,orrotated,hygienedifficult,eliminationofpocketsimpaired牙周病的預(yù)后和計(jì)劃第65頁periodontaldiseaseiscomplicatedbyactivesystemicfactors

andtraumatism牙周病的預(yù)后和計(jì)劃第66頁morphologicinnatureandincludethenumberanddistributionofteeth,toothmorphology,furcationinvolvement.牙周病的預(yù)后和計(jì)劃第67頁Extentofinvolvement.

Isthefurcationpartiallyortotallyinvolved?

Statusofbonesupport.

Ifthebonelevelsarerelativelysound,theefforttosavemaybejustifiable.牙周病的預(yù)后和計(jì)劃第68頁Rootlengthandcrown-rootratiomustbeconsidered牙周病的預(yù)后和計(jì)劃第69頁Angulationofrootspread.

Healthofneighboringteeth.牙周病的預(yù)后和計(jì)劃第70頁Thenumberanddistributionofteethpresent

crown-rootratio,

shapeandnumberoftheroot牙周病的預(yù)后和計(jì)劃第71頁theheightofthealveolarcrest

personalpsychologicandsociologic,

financialconsiderations.牙周病的預(yù)后和計(jì)劃第72頁OTHERCONSIDERATIONSINESTABLISHINGPROGNOSIS牙周病的預(yù)后和計(jì)劃第73頁Theperformanceofhomecareisacceptableandthecariesincidenceislow,

theprognosisisbetter

牙周病的預(yù)后和計(jì)劃第74頁Theprimeconsiderationisthepreservationofthedentitionasafunctioningunit.牙周病的預(yù)后和計(jì)劃第75頁Insomeinstances

theextractionofasingletoothwillmakethewholesituationuntenable.

Inothersituationsisolatedextractionswillsimplifytheproblem.牙周病的預(yù)后和計(jì)劃第76頁whatisconsideredtobeahopelesstooth.

Thiswillmaketreatmentplanningsimpler.

牙周病的預(yù)后和計(jì)劃第77頁thecharacteristicsofhopelessperiodontallyinvolvedteeth:牙周病的預(yù)后和計(jì)劃第78頁Associatedwithintractablepainrelieved,massiveinfectionreducedbyextraction

Mobilitybeyond3degrees牙周病的預(yù)后和計(jì)劃第79頁Furcationinvolvementwithlittleornointerradicularbone

Bonelossbeyondtheapex

Bonelosstotheapexononesideofthetooth牙周病的預(yù)后和計(jì)劃第80頁Generalizedcircumferential

bonelosstowithin3mmoftheapex

Pocketdepthtotheapexwithoutpulpalinvolvement

Verticalcracksorfractures牙周病的預(yù)后和計(jì)劃第81頁Inaccessibleperforationsoraccessory

canals

Numberandpositionofremainingteethprecludingprosthetic

Extremecariessusceptibility牙周病的預(yù)后和計(jì)劃第82頁Objectives

oftreatment牙周病的預(yù)后和計(jì)劃第83頁Treatmentgoalsshouldbe

evaluatedineverycase.牙周病的預(yù)后和計(jì)劃第84頁Cantreatmentobjectivesofafirmnon-retractablegingivathatdoesnotbleedbereached?

Canthepocketbeeliminated?

Willtheboneregenerate?

Canthetoothbestabilized?

牙周病的預(yù)后和計(jì)劃第85頁Cantoothberestored?

Canthepatienttoleratethetreatment?

牙周病的預(yù)后和計(jì)劃第86頁Ifyoubelievetheanswerstothesequestionstobe"yes,"thenplanandproceedwiththetreatment.

If“no,”alternativetreatment,compromise,orextractionisadvisable.牙周病的預(yù)后和計(jì)劃第87頁Asdefinitivelaboratorytestsaredevelopedtomakediagnosismoreaccurate,andasfurtherknowledgeconcerningtheetiologyandpathogenesisofperiodontaldiseasesisdeveloped,prognosiswillchangefromaqualitativetoaquantitativejudgment.

牙周病的預(yù)后和計(jì)劃第88頁TREATMENTPLAN牙周病的預(yù)后和計(jì)劃第89頁P(yáng)resentation

Patientconsent

Orderoftreatment

PhaseI

PhasesIlandIII

MaintenancetherapyProstheticprescription牙周病的預(yù)后和計(jì)劃第90頁Alternativetreatmentplans

Treatmentcriteria

Qualityofcare

Philosophyoftreatment

Recordkeeping

Referral牙周病的預(yù)后和計(jì)劃第91頁P(yáng)resentation

Patientconsent

Afterhearingthepresentation,thepatientmustdecidewhethertoundergotreatment.牙周病的預(yù)后和計(jì)劃第92頁P(yáng)HASEI牙周病的預(yù)后和計(jì)劃第93頁Firststeps(Theinitialeffort)shouldbedirectedtowardtheeliminationofinflammationandtheinstitutionofaprogramofplaquecontrol.

牙周病的預(yù)后和計(jì)劃第94頁Toreducepocketdepth

Tominimizeperiodontaltraumatism

Orthodontics

(mayprecedeorfollowanysurgicalinterventions)牙周病的預(yù)后和計(jì)劃第95頁Extractions

(Teethwithhopelessprognoses)

Restorations

Usuallyperiodontaltherapyshouldprecederestorativeinterventions.

therestorationsshouldbetemporary牙周病的預(yù)后和計(jì)劃第96頁Theprovisionalsplinting

duringthetreatmentperiodshouldbeevaluated.牙周病的預(yù)后和計(jì)劃第97頁Schedulingofrestorativetreatment

shouldbedoneaccordingtothefollowinggeneralrules:牙周病的預(yù)后和計(jì)劃第98頁Normalpatients.

(Restorativetreatmentstartsimmediately.)

ClassI

(ADAperiodontaldiseaseclassification)牙周病的預(yù)后和計(jì)劃第99頁Withoutocclusaltreatmentneed

Cariescontrolandscalingandrootplanning.includingplaquecontrol,maybesimultaneous.Definitiverestorativetreatmentshouldfollowcompletionofscalingandplaquecontrol.牙周病的預(yù)后和計(jì)劃第100頁WithocclusaltreatmentneedDefinitiverestorativetreatmentmayimmediatelyfollowcompletionofscaling,plaquecontrol,andocclusaladjustment.牙周病的預(yù)后和計(jì)劃第101頁WithsurgicaltreatmentneedDefinitiverestorativetreatmentshouldnotbeinstitutedforatleast4to6weeksafterthepatienthashealed.牙周病的預(yù)后和計(jì)劃第102頁Splinting

(Wireligationandcompositeacid-etchsplinting)

Emergency

(pain,swelling,infection,anddiscomfort)

Theemergenciesalltakepriorityoverothertreatmentscheduling.牙周病的預(yù)后和計(jì)劃第103頁Medicalstatus

asystemicconditionthatwouldcomplicatetreatment,amedicalconsultationisnecessary.牙周病的預(yù)后和計(jì)劃第104頁P(yáng)HASESIIANDIII牙周病的預(yù)后和計(jì)劃第105頁P(yáng)haseIIsurgery

permitspocketelimination/reduction

Therestorationofnormalosseousform

ostectomy-osteoplasty

osseoussurgerycombinedwithgraftingprocedures牙周病的預(yù)后和計(jì)劃第106頁rootresections

mucogingivalandgingivectomy

periodontal-endodonticrestorativetreatment

provisionalsplinting.牙周病的預(yù)后和計(jì)劃第107頁Maintenancetherapy

Thespecialistmayseethepatientonceayearoreveryotheryearforthelessinvolvedcases,

whereasthegeneralistmaintainsthepatientintherecallsystem.

Advancedcasesmaybeseenalternatelyat2-to4-monthintervals.牙周病的預(yù)后和計(jì)劃第108頁P(yáng)ROSTHETICPRESCRIPTION

Waitingforaperiodofatleast2monthsafterperiodontalsurgery.

Partialdenturesorafixedprosthesis牙周病的預(yù)后和計(jì)劃第109頁ALTERNATIVETREATMENTPLANS牙周病的預(yù)后和計(jì)劃第110頁Alternativetreatmentplans

shouldbepreparedforthepatientwhoelectstoforegosplintingandsurgerywhentheseareindicated.牙周病的預(yù)后和計(jì)劃第111頁InthiscasethepatientmaybetreatedthroughphaseItherapyandbeplacedonamaintenanceschedule.

Theestablishmentofanalternativeplangenerallycallsforarigorousmaintenanceschedulewithscalingandplaningperformedmorefrequentlythanisotherwiseusual.牙周病的預(yù)后和計(jì)劃第112頁Treatmentcriteria牙周病的預(yù)后和計(jì)劃第113頁Qualityofcare

Ingeneral,periodontalcareseeksthefollowing:

Removalofknownetiologicfactors

Reductionofallpockets

toaminimaldepthtofacilitatemaintenancebythepatientandthedentalhygienist

Creationofamaintainablegingivalandosseousarchitecture牙周病的預(yù)后和計(jì)劃第114頁Restorationofafunctionalandestheticdentition

Maintenanceoftheresultinghealthbythepatient,doctor,andhygienist牙周病的預(yù)后和計(jì)劃第115頁P(yáng)HILOSOPHYOFTREATMENT牙周病的預(yù)后和計(jì)劃第116頁periodontaldiseasescanbetreatedsuccessfully

thehealthofthediseasedperiodontiumcanberestoredandtheteethmaintained.牙周病的預(yù)后和計(jì)劃第117頁Thetherapeuticconceptoftodayincludesallformsoftherapy,conservativeandcomplexselectedandblendedforthesuccessfulmanagementoftheindividualpatient.牙周病的預(yù)后和計(jì)劃第118頁Therapymustbetailoredtotheneeds,bothphysicalandpsychologic,ofthepatient.牙周病的預(yù)后和計(jì)劃第119頁RECORDKEEPING

Thetreatmentperformedshouldberecordedcarefullyateachvisit.牙周病的預(yù)后和計(jì)劃第120頁Referral

Therearethreebasicreasonsforreferral:

(1)professional,

(2)moralanethical,and

(3)legal.牙周病的預(yù)后和計(jì)劃第121頁P(yáng)rofessional:

Professionalreferralsareclassifiedasfollows:

1.

Medical:

Referral/consultation

isindicatedwhenapatient'smedicalhistorydisclosessignificantinformationthatmaycontributetoorinfluencethecourseandoutcomeofthetreatmentorwhenthedentistsuspectsillness.牙周病的預(yù)后和計(jì)劃第122頁2.Dental:

Referral/consultationisindicated

whenthedentistcannotprovidetheentiredentaltherapythepatientneeds.

Whentheexaminationrevealsperiodontaldiseasethatthegeneralistcannotordoesnotwishtotreat,referraltoaperiodontistisinorder.

Equallytheperiodontistisobligatedtoreferpatientsfortreatmenttothegeneralpractitionerorotherspecialists.牙周病的預(yù)后和計(jì)劃第123頁3.Moralandethical:Thespecialists