牙周病的治疗预后计划培训课件

第11章

PROGNOSTICJUDGMENTTREATMENTPLANNING牙周病的预后和计划7/22/20231牙周病的治疗预后计划PROGNOSISPrognosisForecast

预后预测7/22/20232牙周病的治疗预后计划预后类型骨吸收病因依从性全身病变极佳无可消除良好无良好轻较差中难消除差明显/未控制极差重7/22/20233牙周病的治疗预后计划整体预后依据病史、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7/22/20234牙周病的治疗预后计划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7/22/20235牙周病的治疗预后计划牙周炎的预后总预后个别牙预后7/22/20236牙周病的治疗预后计划牙周炎总预后

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7/22/20237牙周病的治疗预后计划骨破坏的速度、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7/22/20238牙周病的治疗预后计划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：7/22/20239牙周病的治疗预后计划牙周病治疗计划7/22/202310牙周病的治疗预后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7/22/202311牙周病的治疗预后计划恢复牙周组织功能

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7/22/202312牙周病的治疗预后计划治疗程序主要分为四个阶段7/22/202313牙周病的治疗预后计划第一阶段

病因治疗基础治疗INITIALTHERAPY消除、控制：致病因素临床炎症7/22/202314牙周病的治疗预后计划包括下列方法：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7/22/202315牙周病的治疗预后计划拔除病牙洁治、刮治、根面平整术药物控制感染咬合调整7/22/202316牙周病的治疗预后计划治疗龋齿，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4~6周再评估，确认疗效、依从性、治疗方案7/22/202317牙周病的治疗预后计划第二个阶段牙周手术治疗并非每个患者都要进行7/22/202318牙周病的治疗预后计划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1~3月全面评估7/22/202319牙周病的治疗预后计划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7/22/202320牙周病的治疗预后计划翻瓣术牙周骨手术骨修整术、植骨GTR膜龈手术牙种植术7/22/202321牙周病的治疗预后计划第三阶段

修复治疗阶段

并非每个患者都要进行2st阶段后2~3月进行松牙固定义齿修复、正畸7/22/202322牙周病的治疗预后计划第四阶段

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：7/22/202323牙周病的治疗预后计划定期复查时间：一般3~6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7/22/202324牙周病的治疗预后计划复治根据发现的问题进行新一轮的治疗与疗效维护7/22/202325牙周病的治疗预后计划牙周治疗与院内感染

P163-164自学7/22/202326牙周病的治疗预后计划OVER

THANKS7/22/202327牙周病的治疗预后计划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。7/22/202328牙周病的治疗预后计划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。7/22/202329牙周病的治疗预后计划我国人群中HBV携带者约占10%，

艾滋病、梅毒等也有增多的趋势。7/22/202330牙周病的治疗预后计划牙周诊室控制感染

特点及原则7/22/202331牙周病的治疗预后计划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。7/22/202332牙周病的治疗预后计划治疗器械的消毒

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。7/22/202333牙周病的治疗预后计划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。7/22/202334牙周病的治疗预后计划保护性屏障

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。7/22/202335牙周病的治疗预后计划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。7/22/202336牙周病的治疗预后计划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。7/22/202337牙周病的治疗预后计划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。7/22/202338牙周病的治疗预后计划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。7/22/202339牙周病的治疗预后计划Treatmentcanalterprognosis.Prognosishasdifferentconnotationsandnuances.Thepatienthaseveryrighttoknowtheanswerstothesequestions.7/22/202340牙周病的治疗预后计划Question？Ismydiseasefatal?

WillIlosemyteeth?

Willyourtreatmenthelpme?

Whatcanyoudotohelpme?7/22/202341牙周病的治疗预后计划Whatarethetherapeutic"odds"?

Whatarethefinancialrisks?

Whatarethechancesthatthetreatmentwillbeofbenefit?7/22/202342牙周病的治疗预后计划Prognosishas

threemeanings

indentistry.7/22/202343牙周病的治疗预后计划Diagnosticprognosis.Whatareevaluationsofthecourseofthediseasewithouttreatment?WhatisthestatusoftheteethnowWhatistheanticipatedfutureoftheseteeth?7/22/202344牙周病的治疗预后计划Therapeuticprognosis.Giventhestateoftheartandscienceofperiodonticsandtheknowledgeandskillofthepractitioner,whateffectwillperiodontaltreatmenthaveonthecourseofthedisease?7/22/202345牙周病的治疗预后计划Prostheticprognosis.Whatistheforecastforthesuccessoftheprostheticrestoration?Willtheprosthesisbetherapeuticordetrimental?Whatspecificneedsdictatethatitbeprescribed?7/22/202346牙周病的治疗预后计划Judgementoftheseveritydependson：1.pocketdepth,2.degreeofboneloss,3.toothmobility,4.crown-rootratio.7/22/202347牙周病的治疗预后计划generalizedorlocalizedThedistributionofdisease：Inflammatoryfactors：Traumaticfactors：7/22/202348牙周病的治疗预后计划Individualtooththerapeuticprognosisincludessuchfactorsas：Percentageofboneloss;Probingdepth;7/22/202349牙周病的治疗预后计划Distributionandtype

ofboneloss

Presenceandseverityof

furcationinvolvements

Mobility7/22/202350牙周病的治疗预后计划Crown-rootratio

Pulpalinvolvement

Toothpositionandocclusal

Strategicvalue7/22/202351牙周病的治疗预后计划Followingarefactorsincludedinoverallprognosis:AgeMedicalstatus7/22/202352牙周病的治疗预后计划Individualtoothprognoses

(distributionandseverity)

Degreeofinvolvement,duration,andhistory

ofthedisease(rateofprogression)7/22/202353牙周病的治疗预后计划Patientcooperation

Economicconsiderations

Knowledgeandabilityofthedentist

Etiologicfactors7/22/202354牙周病的治疗预后计划Accuracyandcompletenessoftheinformationgatheredattheexamination

Dentist'sabilitytorecognizeandeliminateorcontrolthefactorscausingthedisease7/22/202355牙周病的治疗预后计划thepatient'sabilityanddeterminationinmaintainingthehealthoftheperiodontiumandteeth.7/22/202356牙周病的治疗预后计划Theoverallprognosisdependsontheprognosesoftheindividualteeth.7/22/202357牙周病的治疗预后计划PASTHISTORY

(RATEOFDESTRUCTION)7/22/202358牙周病的治疗预后计划Probablythemostimportantfactorinforecastingthefuturehealthstatusofadentitionisknowledgeofitspasthealthstatus.

7/22/202359牙周病的治疗预后计划Speedofbreakdownundercontrolsoruncontrols

Thelocation,shapeanddepthsofthepockets7/22/202360牙周病的治疗预后计划Toothmobilitycanbecontrolledoreliminated,theprognosisisbetter.

Thegreatertheboneloss,thepoorertheprognosis.7/22/202361牙周病的治疗预后计划Asbonelossexceeds50%,theprognosisworsensrapidly.

Themoreirregulartheboneloss,thepoorertheprognosis.7/22/202362牙周病的治疗预后计划thepatternofboneloss:horizontal,verticalorinfrabonydefects.

theageofthepatientandtheetiologicfactorsinvolvedinthepatient'sdisease.7/22/202363牙周病的治疗预后计划poorerprognosis:

tilted,drifted,orrotated,hygienedifficult,eliminationofpocketsimpaired7/22/202364牙周病的治疗预后计划periodontaldiseaseiscomplicatedbyactivesystemicfactors

andtraumatism7/22/202365牙周病的治疗预后计划morphologicinnatureandincludethenumberanddistributionofteeth,toothmorphology,furcationinvolvement.7/22/202366牙周病的治疗预后计划Extentofinvolvement.

Isthefurcationpartiallyortotallyinvolved?

Statusofbonesupport.

Ifthebonelevelsarerelativelysound,theefforttosavemaybejustifiable.7/22/202367牙周病的治疗预后计划Rootlengthandcrown-rootratiomustbeconsidered7/22/202368牙周病的治疗预后计划Angulationofrootspread.

Healthofneighboringteeth.7/22/202369牙周病的治疗预后计划Thenumberanddistributionofteethpresent

crown-rootratio,

shapeandnumberoftheroot7/22/202370牙周病的治疗预后计划theheightofthealveolarcrest

personalpsychologicandsociologic,

financialconsiderations.7/22/202371牙周病的治疗预后计划OTHERCONSIDERATIONSINESTABLISHINGPROGNOSIS7/22/202372牙周病的治疗预后计划Theperformanceofhomecareisacceptableandthecariesincidenceislow,

theprognosisisbetter

7/22/202373牙周病的治疗预后计划Theprimeconsiderationisthepreservationofthedentitionasafunctioningunit.7/22/202374牙周病的治疗预后计划Insomeinstances

theextractionofasingletoothwillmakethewholesituationuntenable.

Inothersituationsisolatedextractionswillsimplifytheproblem.7/22/202375牙周病的治疗预后计划whatisconsideredtobeahopelesstooth.

Thiswillmaketreatmentplanningsimpler.

7/22/202376牙周病的治疗预后计划thecharacteristicsofhopelessperiodontallyinvolvedteeth:7/22/202377牙周病的治疗预后计划Associatedwithintractablepainrelieved,massiveinfectionreducedbyextraction

Mobilitybeyond3degrees7/22/202378牙周病的治疗预后计划Furcationinvolvementwithlittleornointerradicularbone

Bonelossbeyondtheapex

Bonelosstotheapexononesideofthetooth7/22/202379牙周病的治疗预后计划Generalizedcircumferential

bonelosstowithin3mmoftheapex

Pocketdepthtotheapexwithoutpulpalinvolvement

Verticalcracksorfractures7/22/202380牙周病的治疗预后计划Inaccessibleperforationsoraccessory

canals

Numberandpositionofremainingteethprecludingprosthetic

Extremecariessusceptibility7/22/202381牙周病的治疗预后计划Objectives

oftreatment7/22/202382牙周病的治疗预后计划Treatmentgoalsshouldbe

evaluatedineverycase.7/22/202383牙周病的治疗预后计划Cantreatmentobjectivesofafirmnon-retractablegingivathatdoesnotbleedbereached?

Canthepocketbeeliminated?

Willtheboneregenerate?

Canthetoothbestabilized?

7/22/202384牙周病的治疗预后计划Cantoothberestored?

Canthepatienttoleratethetreatment?

7/22/202385牙周病的治疗预后计划Ifyoubelievetheanswerstothesequestionstobe"yes,"thenplanandproceedwiththetreatment.

If“no,”alternativetreatment,compromise,orextractionisadvisable.7/22/202386牙周病的治疗预后计划Asdefinitivelaboratorytestsaredevelopedtomakediagnosismoreaccurate,andasfurtherknowledgeconcerningtheetiologyandpathogenesisofperiodontaldiseasesisdeveloped,prognosiswillchangefromaqualitativetoaquantitativejudgment.

7/22/202387牙周病的治疗预后计划TREATMENTPLAN7/22/202388牙周病的治疗预后计划Presentation

Patientconsent

Orderoftreatment

PhaseI

PhasesIlandIII

MaintenancetherapyProstheticprescription7/22/202389牙周病的治疗预后计划Alternativetreatmentplans

Treatmentcriteria

Qualityofcare

Philosophyoftreatment

Recordkeeping

Referral7/22/202390牙周病的治疗预后计划Presentation

Patientconsent

Afterhearingthepresentation,thepatientmustdecidewhethertoundergotreatment.7/22/202391牙周病的治疗预后计划PHASEI7/22/202392牙周病的治疗预后计划Firststeps(Theinitialeffort)shouldbedirectedtowardtheeliminationofinflammationandtheinstitutionofaprogramofplaquecontrol.

7/22/202393牙周病的治疗预后计划Toreducepocketdepth

Tominimizeperiodontaltraumatism

Orthodontics

(mayprecedeorfollowanysurgicalinterventions)7/22/202394牙周病的治疗预后计划Extractions

(Teethwithhopelessprognoses)

Restorations

Usuallyperiodontaltherapyshouldprecederestorativeinterventions.

therestorationsshouldbetemporary7/22/202395牙周病的治疗预后计划Theprovisionalsplinting

duringthetreatmentperiodshouldbeevaluated.7/22/202396牙周病的治疗预后计划Schedulingofrestorativetreatment

shouldbedoneaccordingtothefollowinggeneralrules:7/22/202397牙周病的治疗预后计划Normalpatients.

(Restorativetreatmentstartsimmediately.)

ClassI

(ADAperiodontaldiseaseclassification)7/22/202398牙周病的治疗预后计划Withoutocclusaltreatmentneed

Cariescontrolandscalingandrootplanning.includingplaquecontrol,maybesimultaneous.Definitiverestorativetreatmentshouldfollowcompletionofscalingandplaquecontrol.7/22/202399牙周病的治疗预后计划WithocclusaltreatmentneedDefinitiverestorativetreatmentmayimmediatelyfollowcompletionofscaling,plaquecontrol,andocclusaladjustment.7/22/2023100牙周病的治疗预后计划WithsurgicaltreatmentneedDefinitiverestorativetreatmentshouldnotbeinstitutedforatleast4to6weeksafterthepatienthashealed.7/22/2023101牙周病的治疗预后计划Splinting

(Wireligationandcompositeacid-etchsplinting)

Emergency

(pain,swelling,infection,anddiscomfort)

Theemergenciesalltakepriorityoverothertreatmentscheduling.7/22/2023102牙周病的治疗预后计划Medicalstatus

asystemicconditionthatwouldcomplicatetreatment,amedicalconsultationisnecessary.7/22/2023103牙周病的治疗预后计划PHASESIIANDIII7/22/2023104牙周病的治疗预后计划PhaseIIsurgery

permitspocketelimination/reduction

Therestorationofnormalosseousform

ostectomy-osteoplasty

osseoussurgerycombinedwithgraftingprocedures7/22/2023105牙周病的治疗预后计划rootresections

mucogingivalandgingivectomy

periodontal-endodonticrestorativetreatment

provisionalsplinting.7/22/2023106牙周病的治疗预后计划Maintenancetherapy

Thespecialistmayseethepatientonceayearoreveryotheryearforthelessinvolvedcases,

whereasthegeneralistmaintainsthepatientintherecallsystem.

Advancedcasesmaybeseenalternatelyat2-to4-monthintervals.7/22/2023107牙周病的治疗预后计划PROSTHETICPRESCRIPTION

Waitingforaperiodofatleast2monthsafterperiodontalsurgery.

Partialdenturesorafixedprosthesis7/22/2023108牙周病的治疗预后计划ALTERNATIVETREATMENTPLANS7/22/2023109牙周病的治疗预后计划Alternativetreatmentplans

shouldbepreparedforthepatientwhoelectstoforegosplintingandsurgerywhentheseareindicated.7/22/2023110牙周病的治疗预后计划InthiscasethepatientmaybetreatedthroughphaseItherapyandbeplacedonamaintenanceschedule.

Theestablishmentofanalternativeplangenerallycallsforarigorousmaintenanceschedulewithscalingandplaningperformedmorefrequentlythanisotherwiseusual.7/22/2023111牙周病的治疗预后计划Treatmentcriteria7/22/2023112牙周病的治疗预后计划Qualityofcare

Ingeneral,periodontalcareseeksthefollowing:

Removalofknownetiologicfactors

Reductionofallpockets

toaminimaldepthtofacilitatemaintenancebythepatientandthedentalhygienist

Creationofamaintainablegingivalandosseousarchitecture7/22/2023113牙周病的治疗预后计划Restorationofafunctionalandestheticdentition

Maintenanceoftheresultinghealthbythepatient,doctor,andhygienist7/22/2023114牙周病的治疗预后计划PHILOSOPHYOFTREATMENT7/22/2023115牙周病的治疗预后计划periodontaldiseasescanbetreatedsuccessfully

thehealthofthediseasedperiodontiumcanberestoredandtheteethmaintained.7/22/2023116牙周病的治疗预后计划Thetherapeuticconceptoftodayincludesallformsoftherapy,conservativeandcomplexselectedandblendedforthesuccessfulmanagementoftheindividualpatient.7/22/2023117牙周病的治疗预后计划Therapymustbetailoredtotheneeds,bothphysicalandpsychologic,ofthepatient.7/22/2023118牙周病的治疗预后计划RECORDKEEPING

Thetreatmentperformedshouldberecordedcarefullyateachvisit.7/22/2023119牙周病的治疗预后计划Referral

Therearethreebasicreasonsforreferral:

(1)professional,

(2)moralanethical,and

(3)legal.7/22/2023120牙周病的治疗预后计划Professional:

Professionalreferralsareclassifiedasfollows:

1.

Medical:

Referral/consultation

isindicatedwhenapatient'smedicalhistorydisclosessignificantinformationthatmaycontributetoorinfluencethecourseandoutcomeofthetreatmentorwhenthedentistsuspectsillness.7/22/2023121牙周病的治疗预后计划2.Dental:

Referral/consultationisindicated

whenthedentistcannotprovidetheentiredentaltherapythepatientneeds.

Whentheexaminationrevealsperiodontaldiseasethatthegeneralistcannotordoesnotwishtotreat,referraltoaperiodontistisinorder.

Equallytheperiodontistisobligatedtoreferpatientsfortreatmenttothegeneralpractitionerorotherspecialists.7/22/2023122牙周病的治疗预后计划3.Moral