牙周病的治疗(预后、计划)ppt医学课件.ppt

PROGNOSTIC JUDGMENT TREATMENT PLANNING,牙周病的预后和计划,1,PROGNOSIS,PrognosisForecast 预后预测,2,预 后 类 型,3,整体预后依据,病史、年龄,疾病类型 发展速度,全身因素 环境因素,患者意愿、依从性,菌斑 牙石量 解剖,牙周破坏程度,4,有全身因素的牙龈炎 全身因素控制后可以痊愈,龈炎的预后 单纯性龈炎：良好,5,牙周炎的预后,总预后 个别牙预后,6,牙周炎总预后 对整个牙列预后的评估，内容包括,牙周炎的类型 单因素轻中度CP，疗效易巩固 有全身因素的牙周炎，变化多样,7,骨破坏的速度、程度、类型,局部因素消除情况: 菌斑、根分叉问题、咬合 牙松动 余留牙的数目、分布； 患者依从性 环境与行为因素 全身、遗传、年龄因素,8,牙周炎个别牙预后,探诊深度、附着水平： 部位？程度？ 袋深浅不是决定的因素。 牙槽骨： 破坏部位、程度、根分叉病变； 牙松动度： 自限性？进行性牙松动？ 牙解剖：,9,牙周病治疗计划,10,总体目标,控制菌斑、炎症 合理的牙周组织形态 纠正：牙周袋 龈退缩 骨缺损 牙松动 牙齿及邻接关系,11,恢复牙周组织功能 合理的咬合关系 修复失牙 戒除不良习惯,维持长期疗效防复发 口腔卫生指导与菌斑控制 定期检查,12,治疗程序,主要分为四个阶段,13,第一阶段 病因治疗,基础治疗 INITIAL THERAPY 消除、控制：致病因素 临床炎症,14,包括下列方法：,自我控制菌斑的方法： 刷牙方法和习惯； 牙线和牙签； 菌斑显示剂检查 漱口剂,15,拔除病牙,洁治、刮治、根面平整术 药物控制感染 咬合调整,16,治疗龋齿，矫正不良修复体和食物嵌塞,处理牙周-牙髓病变,1st阶段结束后46周再评估，确认 疗效、依从性、治疗方案,17,第二个阶段,牙周手术治疗 并非每个患者都要进行,18,牙周手术目的,清除袋内感染物 根面平整 治疗牙槽骨缺损 纠正龈及膜龈畸形 基础治疗后13月全面评估,19,手术的种类,牙龈切除术 切除肥大增生的牙龈 病理性牙周袋,20,翻瓣术,牙周骨手术 骨修整术、植骨 GTR 膜龈手术 牙种植术,21,第三阶段 修复治疗阶段 并非每个患者都要进行,2st阶段后23月进行 松牙固定 义齿修复、正畸,22,第四阶段 疗效维护期,1st阶段后无论是否需要进行2、3阶段治疗即应当开始，内容包括：,23,定期复查,时间：一般36个月1次。 内容： PLI、CI、DI、GI、BOP、PD、 附着水平、牙松动度、 咬合情况、骨高度、密度、 危险因素：吸烟、全身疾病,24,复治,根据发现的问题进行新一轮的治疗与疗效维护,25,牙周治疗与院内感染,P163-164自学,26,OVER THANKS,27,牙周治疗与院内感染 交叉感染 是医院内感染(NOSOCOMIAL INFECTION)中的重要内容之一。,28,医院感染的传播途径有：,直接接触病损、血液、体液、龈沟液、菌斑等； 吸人含致病菌的气雾或飞溅物(如血液、唾液等)； 间接接触(污染器械、手、治疗台等传染媒体)； 手机供水管道中的存水返流人口中。,29,我国人群中HBV携带者约占10%， 艾滋病、梅毒等也有增多的趋势。,30,牙周诊室控制感染 特点及原则,31,病史采集及必要的检查 重视询问全身疾病、传染性疾病。 “一致对待”原则 universal precaution 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，必要时作有关的化验检查。,32,治疗器械的消毒 按器械分类、分别用不同的方法消毒。 “双消毒”：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、高压灭菌或其他消毒方法。 大型设备如综合治疗台表面等， 可用可靠的消毒剂进行表面擦拭等。,33,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)。 一人一机。 也可2%碘酊擦拭手机的各部位，酒精脱碘2次， 也可用1%碘附消毒。,34,保护性屏障 口罩、帽子、防护眼镜、面罩、手套、工作服等 治疗过程中， 污染的手套不得任意触摸周围的物品， 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。,35,尽量使用脚控开关来调节治疗椅 照明灯扶手、开关等可用一次性覆盖物覆盖。一次性器械及覆盖物在用毕后应妥善、单独回收，作必要的销毁。,36,减少治疗椅周围空气中的细菌量 治疗前1%过氧化氢或0.12%氯己定液鼓漱一分钟，减少患者口中的细菌数量、治疗时的气雾污染。 诊室内应有良好的通风。 不在诊室内饮水和进食。,37,治疗台水管系统的消毒、 阻止水回流的装置； 在每位患者治疗结束后，再空放水30秒； 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水器，并每周用1:10的次氯酸钠液冲储水系统，随后立即用蒸馏水冲洗。,38,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降低到最小的程度。 保护患者和医务人员的利益安全。,39,Treatment can alter prognosis.,Prognosis has different connotations and nuances.,The patient has every right to know the answers to these questions.,40,Question？,Is my disease fatal? Will I lose my teeth? Will your treatment help me? What can you do to help me?,41,What are the therapeutic “odds“? What are the financial risks? What are the chances that the treatment will be of benefit?,42,Prognosis has three meanings in dentistry.,43,Diagnostic prognosis.,What are evaluations of the course of the disease without treatment? What is the status of the teeth now What is the anticipated future of these teeth?,44,Therapeutic prognosis.,Given the state of the art and science of periodontics and the knowledge and skill of the practitioner, what effect will periodontal treatment have on the course of the disease?,45,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?,46,Judgement of the severity depends on ：,1. pocket depth, 2. degree of bone loss, 3. tooth mobility, 4. crown-root ratio.,47,generalized or localized,The distribution of disease： Inflammatory factors ： Traumatic factors：,48,Individual tooth therapeutic prognosis,includes such factors as ： Percentage of bone loss; Probing depth;,49,Distribution and type of bone loss Presence and severity of furcation involvements Mobility,50,Crown-root ratio Pulpal involvement Tooth position and occlusal Strategic value,51,Following are factors included in overall prognosis:,Age Medical status,52,Individual tooth prognoses (distribution and severity) Degree of involvement, duration, and history of the disease (rate of progression),53,Patient cooperation Economic considerations Knowledge and ability of the dentist Etiologic factors,54,Accuracy and completeness of the information gathered at the examination Dentists ability to recognize and eliminate or control the factors causing the disease,55,the patients ability and determination in maintaining the health of the periodontium and teeth.,56,The overall prognosis depends on the prognoses of the individual teeth.,57,PAST HISTORY (RATE OF DESTRUCTION),58,Probably the most important factor in forecasting the future health status of a dentition is knowledge of its past health status.,59,Speed of breakdown under controls or uncontrols The location, shape and depths of the pockets,60,Tooth mobility can be controlled or eliminated, the prognosis is better. The greater the bone loss, the poorer the prognosis.,61,As bone loss exceeds 50%, the prognosis worsens rapidly. The more irregular the bone loss, the poorer the prognosis.,62,the pattern of bone loss: horizontal, vertical or infrabony defects. the age of the patient and the etiologic factors involved in the patients disease.,63,poorer prognosis: tilted, drifted, or rotated, hygiene difficult, elimination of pockets impaired,64,periodontal disease is complicated by active systemic factors and traumatism,65,morphologic in nature and include the number and distribution of teeth, tooth morphology, furcation involvement.,66,Extent of involvement. Is the furcation partially or totally involved? Status of bone support. If the bone levels are relatively sound, the effort to save may be justifiable.,67,Root length and crown-root ratio must be considered,68,Angulation of root spread. Health of neighboring teeth.,69,The number and distribution of teeth present crown-root ratio, shape and number of the root,70,the height of the alveolar crest personal psychologic and sociologic, financial considerations.,71,OTHER CONSIDERATIONS IN ESTABLISHING PROGNOSIS,72,The performance of home care is acceptable and the caries incidence is low, the prognosis is better,73,The prime consideration is the preservation of the dentition as a functioning unit.,74,In some instances the extraction of a single tooth will make the whole situation untenable. In other situations isolated extractions will simplify the problem.,75,what is considered to be a hopeless tooth. This will make treatment planning simpler.,76,the characteristics of hopeless periodontally involved teeth:,77,Associated with intractable pain relieved, massive infection reduced by extraction Mobility beyond 3 degrees,78,Furcation involvement with little or no interradicularbone Bone loss beyond the apex Bone loss to the apex on one side of the tooth,79,Generalized circumferential bone loss to within 3 mm of the apex Pocket depth to the apex without pulpal involvement Vertical cracks or fractures,80,Inaccessible perforations or accessory canals Number and position of remaining teeth precluding prosthetic Extreme caries susceptibility,81,Objectives of treatment,82,Treatment goals should be evaluated in every case.,83,Can treatment objectives of a firm non-retractable gingiva that does not bleed be reached? Can the pocket be eliminated? Will the bone regenerate? Can the tooth be stabilized?,84,Can tooth be restored? Can the patient tolerate the treatment?,85,If you believe the answers to these questions to be “yes,“ then plan and proceed with the treatment. If “no,” alternative treatment, compromise, or extraction is advisable.,86,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 quantitative judgment.,87,TREATMENT PLAN,88,Presentation Patient consent Order of treatment Phase I Phases Il and III Maintenance therapyProsthetic prescription,89,Alternative treatment plans Treatment criteria Quality of care Philosophy of treatment Record keeping Referral,90,Presentation Patient consent After hearing the presentation, the patient must decide whether to undergo treatment.,91,PHASE I,92,First steps (The initial effort) should be directed toward the elimination of inflammation and the institution of a program of plaque control.,93,To reduce pocket depth To minimize periodontal traumatism Orthodontics (may precede or follow any surgical interventions),94,Extractions (Teeth with hopeless prognoses) Restorations Usually periodontal therapy should precede restorative interventions. the restorations should be temporary,95,The provisional splinting during the treatment period should be evaluated.,96,Scheduling of restorative treatment should be done according to the following general rules:,97,Normal patients. (Restorative treatment starts immediately.) Class I (ADA periodontal disease classification),98,Without occlusal treatment need Caries control and scaling and root planning. including plaque control, may be simultaneous. Definitive restorative treatment should follow completion of scaling and plaque control.,99,With occlusal treatment need Definitive restorative treatment may immediately follow completion of scaling, plaque control, and occlusal adjustment.,100,With surgical treatment need Definitive restorative treatment should not be instituted for at least 4 to 6 weeks after the patient has healed.,101,Splinting (Wire ligation and composite acid-etch splinting) Emergency (pain, swelling, infection, and discomfort) The emergencies all take priority over other treatment scheduling.,102,Medical status a systemic condition that would complicate treatment, a medical consultation is necessary.,103,PHASES II AND III,104,Phase II surgery permits pocket elimination / reduction The restoration of normal osseous form ostectomy-osteoplasty osseous surgery combined with grafting procedures,105,root resections mucogingival and gingivectomy periodontal-endodontic restorative treatment provisional splinting.,106,Maintenance therapy The 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.,107,PROSTHETIC PRESCRIPTION Waiting for a period of at least 2 months after periodontal surgery. Partial dentures or a fixed prosthesis,108,ALTERNATIVE TREATMENT PLANS,109,Alternative treatment plans should be prepared for the patient who elects to forego splinting and surgery when these are indicated.,110,In 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 performed more frequently than is otherwise usual.,111,Treatment criteria,112,Quality of care In general, periodontal care seeks the following: Removal of known etiologic factors Reduction of all pockets to a minimal depth to facilitate maintenance by the patient and the dental hygienist Creation of a maintainable gingival and osseous architecture,113,Restoration of a functional and esthetic dentition Maintenance of the resulting health by the patient, doctor, and hygienist,114,PHILOSOPHY OF TREATMENT,115,periodontal diseases can be treated successfully the health of the diseased periodontium can be restored and the teeth maintained.,116,The therapeutic concept of today includes all forms of therapy, conservative and complex selected and blended for the successful management of the individual patient.,117,Therapy must be tailored to the needs, both physical and psychologic, of the patient.,118,RECORD KEEPING The treatment performed should be recorded carefully at each visit.,119,Referral There are three basic reasons for referral: (1) professional, (2) moral an ethical, and (3) legal.,120,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 treatment or when the dentist suspects illness.,121,2.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 practitioner or other specialists.,122,3.Moral and ethical:,The specialists or consulting dentists upon completion of their care shall return the patie