牙周病的预后和计划.ppt

QUESTION？,Ismydiseasefatal?WillIlosemyteeth?Willyourtreatmenthelpme?Whatcanyoudotohelpme?,第11章PROGNOSTICJUDGMENTTREATMENTPLANNING,牙周病的预后和计划,PROGNOSIS,PrognosisForecast预后预测,预后类型,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,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,牙周炎的预后,总预后个别牙预后,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,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,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：,牙周病治疗计划,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,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,治疗程序,主要分为四个阶段,第一阶段病因治疗,基础治疗INITIALTHERAPY消除、控制：致病因素临床炎症,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,拔除病牙,洁治、刮治、根面平整术药物控制感染咬合调整,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,第二个阶段,牙周手术治疗并非每个患者都要进行,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,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,翻瓣术,牙周骨手术骨修整术、植骨GTR膜龈手术牙种植术,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,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：,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,复治,根据发现的问题进行新一轮的治疗与疗效维护,牙周治疗与院内感染,P163-164自学,OVERTHANKS,牙周治疗与院内感染交叉感染是医院内感染(NOSOCOMIALINFECTION)中的重要内容之一。,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。,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。,牙周诊室控制感染特点及原则,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universalprecaution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。,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。,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。,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。,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。,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。,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。,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。,Treatmentcanalterprognosis.,Prognosishasdifferentconnotationsandnuances.,Thepatienthaseveryrighttoknowtheanswerstothesequestions.,Question？,Ismydiseasefatal?WillIlosemyteeth?Willyourtreatmenthelpme?Whatcanyoudotohelpme?,Whatarethetherapeuticodds?Whatarethefinancialrisks?Whatarethechancesthatthetreatmentwillbeofbenefit?,Prognosishasthreemeaningsindentistry.,Diagnosticprognosis.,Whatareevaluationsofthecourseofthediseasewithouttreatment?WhatisthestatusoftheteethnowWhatistheanticipatedfutureoftheseteeth?,Therapeuticprognosis.,Giventhestateoftheartandscienceofperiodonticsandtheknowledgeandskillofthepractitioner,whateffectwillperiodontaltreatmenthaveonthecourseofthedisease?,Prostheticprognosis.,Whatistheforecastforthesuccessoftheprostheticrestoration?Willtheprosthesisbetherapeuticordetrimental?Whatspecificneedsdictatethatitbeprescribed?,Judgementoftheseveritydependson：,1.pocketdepth,2.degreeofboneloss,3.toothmobility,4.crown-rootratio.,generalizedorlocalized,Thedistributionofdisease：Inflammatoryfactors：Traumaticfactors：,Individualtooththerapeuticprognosis,includessuchfactorsas：Percentageofboneloss;Probingdepth;,DistributionandtypeofbonelossPresenceandseverityoffurcationinvolvementsMobility,Crown-rootratioPulpalinvolvementToothpositionandocclusalStrategicvalue,Followingarefactorsincludedinoverallprognosis:,AgeMedicalstatus,Individualtoothprognoses(distributionandseverity)Degreeofinvolvement,duration,andhistoryofthedisease(rateofprogression),PatientcooperationEconomicconsiderationsKnowledgeandabilityofthedentistEtiologicfactors,AccuracyandcompletenessoftheinformationgatheredattheexaminationDentistsabilitytorecognizeandeliminateorcontrolthefactorscausingthedisease,thepatientsabilityanddeterminationinmaintainingthehealthoftheperiodontiumandteeth.,Theoverallprognosisdependsontheprognosesoftheindividualteeth.,PASTHISTORY(RATEOFDESTRUCTION),Probablythemostimportantfactorinforecastingthefuturehealthstatusofadentitionisknowledgeofitspasthealthstatus.,SpeedofbreakdownundercontrolsoruncontrolsThelocation,shapeanddepthsofthepockets,Toothmobilitycanbecontrolledoreliminated,theprognosisisbetter.Thegreatertheboneloss,thepoorertheprognosis.,Asbonelossexceeds50%,theprognosisworsensrapidly.Themoreirregulartheboneloss,thepoorertheprognosis.,thepatternofboneloss:horizontal,verticalorinfrabonydefects.theageofthepatientandtheetiologicfactorsinvolvedinthepatientsdisease.,poorerprognosis:tilted,drifted,orrotated,hygienedifficult,eliminationofpocketsimpaired,periodontaldiseaseiscomplicatedbyactivesystemicfactorsandtraumatism,morphologicinnatureandincludethenumberanddistributionofteeth,toothmorphology,furcationinvolvement.,Extentofinvolvement.Isthefurcationpartiallyortotallyinvolved?Statusofbonesupport.Ifthebonelevelsarerelativelysound,theefforttosavemaybejustifiable.,Rootlengthandcrown-rootratiomustbeconsidered,Angulationofrootspread.Healthofneighboringteeth.,Thenumberanddistributionofteethpresentcrown-rootratio,shapeandnumberoftheroot,theheightofthealveolarcrestpersonalpsychologicandsociologic,financialconsiderations.,OTHERCONSIDERATIONSINESTABLISHINGPROGNOSIS,Theperformanceofhomecareisacceptableandthecariesincidenceislow,theprognosisisbetter,Theprimeconsiderationisthepreservationofthedentitionasafunctioningunit.,Insomeinstancestheextractionofasingletoothwillmakethewholesituationuntenable.Inothersituationsisolatedextractionswillsimplifytheproblem.,whatisconsideredtobeahopelesstooth.Thiswillmaketreatmentplanningsimpler.,thecharacteristicsofhopelessperiodontallyinvolvedteeth:,Associatedwithintractablepainrelieved,massiveinfectionreducedbyextractionMobilitybeyond3degrees,FurcationinvolvementwithlittleornointerradicularboneBonelossbeyondtheapexBonelosstotheapexononesideofthetooth,Generalizedcircumferentialbonelosstowithin3mmoftheapexPocketdepthtotheapexwithoutpulpalinvolvementVerticalcracksorfractures,InaccessibleperforationsoraccessorycanalsNumberandpositionofremainingteethprecludingprostheticExtremecariessusceptibility,Objectivesoftreatment,Treatmentgoalsshouldbeevaluatedineverycase.,Cantreatmentobjectivesofafirmnon-retractablegingivathatdoesnotbleedbereached?Canthepocketbeeliminated?Willtheboneregenerate?Canthetoothbestabilized?,Cantoothberestored?Canthepatienttoleratethetreatment?,Ifyoubelievetheanswerstothesequestionstobeyes,thenplanandproceedwiththetreatment.If“no,”alternativetreatment,compromise,orextractionisadvisable.,Asdefinitivelaboratorytestsaredevelopedtomakediagnosismoreaccurate,andasfurtherknowledgeconcerningtheetiologyandpathogenesisofperiodontaldiseasesisdeveloped,prognosiswillchangefromaqualitativetoaquantitativejudgment.,TREATMENTPLAN,PresentationPatientconsentOrderoftreatmentPhaseIPhasesIlandIIIMaintenancetherapyProstheticprescription,AlternativetreatmentplansTreatmentcriteriaQualityofcarePhilosophyoftreatmentRecordkeepingReferral,PresentationPatientconsentAfterhearingthepresentation,thepatientmustdecidewhethertoundergotreatment.,PHASEI,Firststeps(Theinitialeffort)shouldbedirectedtowardtheeliminationofinflammationandtheinstitutionofaprogramofplaquecontrol.,ToreducepocketdepthTominimizeperiodontaltraumatismOrthodontics(mayprecedeorfollowanysurgicalinterventions),Extractions(Teethwithhopelessprognoses)RestorationsUsuallyperiodontaltherapyshouldprecederestorativeinterventions.therestorationsshouldbetemporary,Theprovisionalsplintingduringthetreatmentperiodshouldbeevaluated.,Schedulingofrestorativetreatmentshouldbedoneaccordingtothefollowinggeneralrules:,Normalpatients.(Restorativetreatmentstartsimmediately.)ClassI(ADAperiodontaldiseaseclassification),WithoutocclusaltreatmentneedCariescontrolandscalingandrootplanning.includingplaquecontrol,maybesimultaneous.Definitiverestorativetreatmentshouldfollowcompletionofscalingandplaquecontrol.,WithocclusaltreatmentneedDefinitiverestorativetreatmentmayimmediatelyfollowcompletionofscaling,plaquecontrol,andocclusaladjustment.,WithsurgicaltreatmentneedDefinitiverestorativetreatmentshouldnotbeinstitutedforatleast4to6weeksafterthepatienthashealed.,Splinting(Wireligationandcompositeacid-etchsplinting)Emergency(pain,swelling,infection,anddiscomfort)Theemergenciesalltakepriorityoverothertreatmentscheduling.,Medicalstatusasystemicconditionthatwouldcomplicatetreatment,amedicalconsultationisnecessary.,PHASESIIANDIII,PhaseIIsurgerypermitspocketelimination/reductionTherestorationofnormalosseousformostectomy-osteoplastyosseoussurgerycombinedwithgraftingprocedures,rootresectionsmucogingivalandgingivectomyperiodontal-endodonticrestorativetreatmentprovisionalsplinting.,MaintenancetherapyThespecialistmayseethepatientonceayearoreveryotheryearforthelessinvolvedcases,whereasthegeneralistmaintainsthepatientintherecallsystem.Advancedcasesmaybeseenalternatelyat2-to4-monthintervals.,PROSTHETICPRESCRIPTIONWaitingforaperiodofatleast2monthsafterperiodontalsurgery.Partialdenturesorafixedprosthesis,ALTERNATIVETREATMENTPLANS,Alternativetreatmentplansshouldbepreparedforthepatientwhoelectstoforegosplintingandsurgerywhentheseareindicated.,InthiscasethepatientmaybetreatedthroughphaseItherapyandbeplacedonamaintenanceschedule.Theestablishmentofanalternativeplangenerallycallsforarigorousmaintenanceschedulewithscalingandplaningperformedmorefrequentlythanisotherwiseusual.,Treatmentcriteria,QualityofcareIngeneral,periodontalcareseeksthefollowing:RemovalofknownetiologicfactorsReductionofallpocketstoaminimaldepthtofacilitatemaintenancebythepatientandthedentalhygienistCreationofamaintainablegingivalandosseousarchitecture,RestorationofafunctionalandestheticdentitionMaintenanceoftheresultinghealthbythepatient,doctor,andhygienist,PHILOSOPHYOFTREATMENT,periodontaldiseasescanbetreatedsuccessfullythehealthofthediseasedperiodontiumcanberestoredandtheteethmaintained.,Thetherapeuticconceptoftodayincludesallformsoftherapy,conservativeandcomplexselectedandblendedforthesuccessfulmanagementoftheindividualpatient.,Therapymustbetailoredtotheneeds,bothphysicalandpsychologic,ofthepatient.,RECORDKEEPINGThetreatmentperformedshouldberecordedcarefullyateachvisit.,ReferralTherearethreebasicreasonsforreferral:(1)professional,(2)moralanethical,and(3)legal.,Professional:Professionalreferralsareclassifiedasfollows:1.Medical:Referral/consultationisindicatedwhenapatientsmedicalhistorydisclosessignificantinformationthatmaycontributetoorinfluencethecourseandoutcomeofthetreatmentorwhenthedentistsuspectsillness.,2.Dental:Referral/consultationisindicatedwhenthedentistcannotprovidetheentiredentaltherapythepatientneeds.Whentheexaminationrevealsperiodontaldiseasethatthegeneralistcannotordoesnotwishtotreat,referraltoaperiodontistisinorder.Equallytheperiodontistisobligatedtoreferpatientsfortreatmenttothegeneralpractitionerorotherspecialists.,3.Moralandethical:,Thespecialistsorconsultingdentistsuponcompletion