師姐給大四下預(yù)防課件窩溝封閉

窩溝封閉（Pit-and-fissure

sealants）Q.H.

Zhi支清惠窩溝封閉于1967年由CuetoandBuonocore首次報道，今天在牙科被廣泛應(yīng)用和推薦。兒童的點隙窩溝齲流行病學(xué)流行率:咬合面齲損占總的齲損的50.9%6~7

years

old12~14

years

old44%65%氟化物防齲對窩溝齲效果不理想窩溝是齲損易發(fā)部位咬合面的解剖結(jié)構(gòu)

容易滯留細(xì)菌有機(jī)塞、食物殘渣、菌斑阻塞窩溝點隙，阻止了氟化物的滲透較薄的牙釉質(zhì)層

對齲病易感窩溝的解剖形態(tài)淺而寬，容易清潔深而窄，容易滯留食物殘渣和細(xì)菌，窩溝的分類V型I

型不易清潔窩溝齲的發(fā)展齲損首先發(fā)生在側(cè)壁進(jìn)展至窩溝底部三角形病損進(jìn)展期預(yù)防窩溝齲的歷史回顧預(yù)防性充填法（Prophylacticodontotomy）制備I類洞，銀汞充填窩溝磨除術(shù)（Prophylacticodontoplasty）以圓鉆磨除深窩溝窩溝封閉（Pit

and

fissure

sealant）窩溝封閉的發(fā)展歷史第一代:365nm

紫外光固化,操作時間長,效果不理想第二代:Bis-GMA,

化學(xué)固化第三代:430~490nm

可見光,方便，效果好3M

Consisesealant第四代:釋氟性窩溝封閉劑Pulpdentsealant窩溝封閉適應(yīng)證萌出少于4年磨牙深的、易滯留、窄的窩溝點隙窩溝有軟化和混濁傾向其他牙齒有咬合面或光滑面齲；被封閉牙沒有鄰面齲患者接受適當(dāng)?shù)娜硇曰蚓植坑梅?，但仍然齲活躍窩溝封閉非適應(yīng)證牙齒萌出四年以上，窩溝經(jīng)常有色素沉著牙齒未完全萌出，有牙齦覆蓋除非患者為齲活躍個體，否則前磨牙不作窩溝封閉牙面窩溝淺而寬，自潔作用好患牙有鄰面齲，已有咬合面齲洞（需用充填治療）患者飲用水源不含氟，患者不能配合齲病預(yù)防計劃封閉劑成分樹脂基質(zhì)Resin

baseBis-GMA稀釋劑Thinner

(dicrease

the

viscosity) methyl

methacrylate

(MMA)et

al.引發(fā)劑Initiator self-curelight-cure

(430~490nm

visible

light)填料Filling

(increase

the

compressivestrenth,

rigidity

and

abrasive

resistance)顏色Color (easy

to

identify)酸蝕技術(shù)1955由Buonocore首先介紹35~38%磷酸恒牙30秒乳牙60

秒有機(jī)質(zhì)含量高 更耐酸酸蝕使光滑的牙釉質(zhì)表面變得不規(guī)則，增加其表面自由能。當(dāng)液體樹脂基質(zhì)置于不規(guī)則的酸蝕表面，樹脂通過毛細(xì)管作用浸入表面，單體聚合，樹脂扣入牙釉質(zhì)表面。樹脂微突的形成是封閉劑-牙釉質(zhì)粘結(jié)的基本機(jī)制。酸蝕技術(shù)牙釉質(zhì)酸蝕形成三種微結(jié)構(gòu)形式:釉小柱核心溶解，周圍不溶解釉小柱周圍溶解，核心完好不典型形態(tài)操作步驟牙面清潔Teeth

cleaning酸蝕Acid-etch沖洗吹干Washing

and

evaporation放置封閉劑Sealant

application封閉劑固化Solidify

of

sealants檢查Examination操作步驟1.

牙面清潔Teeth

cleaningcleaning

teeth

thoroughlyslow

speed

hand

piece,

mini

dental

brush

orrubbercap,pumice

powderor

dentifrices

withoutfluoride注意:不能使用脂類清潔劑或含填料的磨料必要時去除可疑齲操作步驟2.

酸蝕Acid-etch35%磷酸,2/3

牙尖斜面,恒牙30s,

乳牙60s,注意:輕輕攪拌以保證牙面接觸新鮮的酸，不能污染酸蝕面，酸蝕后的白堊色操作步驟3.

沖洗和干燥Washing

and

evaporation徹底沖洗以去除酸及反應(yīng)產(chǎn)物,以壓縮空氣或無色酒精干燥注意：不污染酸蝕面,白堊色操作步驟4.

放置封閉劑自凝性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操作步驟5.

封閉劑的固化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操作步驟6.

檢測及調(diào)牙合（必要時）固化情況、粘結(jié)、氣泡、遺漏點隙、過度封閉、調(diào)牙合檢查after

3

months,

6

months

or

1

year

interval,脫落重新封閉臨床效果臨床評價保留率retention

rate=封閉劑保留的牙數(shù)/所有檢查的牙齒X100%齲降低相對有效率relative

effectiveness

of

decreased

dental

caries=（對照組患齲率-實驗組患齲率）/對照組患齲率X100%臨床效果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.與臨床效果有關(guān)的其他因素下頜保留率比上頜高前磨牙保留率比磨牙高大多數(shù)脫落發(fā)生在前6個月，重新封閉增加了齲病預(yù)防效果成功率因牙齒的選擇、術(shù)者的技巧、工作態(tài)度而異系統(tǒng)性評價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.影響窩溝封閉預(yù)防效果的因素窩溝封閉對預(yù)防齲病是有效的自凝性封閉劑比光固化的更有效封閉劑的預(yù)防效果隨時間遞減封閉劑和加氟聯(lián)合預(yù)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窩溝封閉的其他問題酸蝕后牙面的齲易感性即使封閉劑脫落，酸蝕后牙面在酸性溶液中的溶解度與未酸蝕牙面相近酸蝕后牙面唾液污染唾液污染阻止了樹脂微突的形成，造成封閉劑脫落、細(xì)菌侵入，引起齲齒以壓縮空氣、橡皮障或棉卷隔濕唾液污染后重新酸蝕窩溝封閉的其他問題早期窩溝齲的封閉酸蝕

殺死窩溝中的微生物封閉劑

阻止細(xì)菌的營養(yǎng)供應(yīng)酸蝕后少于3%細(xì)菌存活在窩溝封閉后早期齲停止進(jìn)展封閉性充填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