1、QUESTION？,Is my disease fatal?Will I lose my teeth?Will your treatment help me?What can you do to help me?,第 11 章 PROGNOSTIC JUDGMENT TREATMENT PLANNING,牙周病的預(yù)后和計(jì)劃,PROGNOSIS,PrognosisForecast預(yù)后預(yù)測(cè),預(yù) 后 類 型,整體預(yù)后依據(jù),病史、年齡,疾病類型 發(fā)展速度,全身因素 環(huán)境因素,患者意愿、依從性,菌斑 牙石量 解剖,牙周破壞程度,有全身因素的牙齦炎全身因素控制后可以痊愈,齦炎的預(yù)后單純性齦炎：良好,牙周炎

2、的預(yù)后,總預(yù)后 個(gè)別牙預(yù)后,牙周炎總預(yù)后對(duì)整個(gè)牙列預(yù)后的評(píng)估，內(nèi)容包括,牙周炎的類型 單因素輕中度CP，療效易鞏固 有全身因素的牙周炎，變化多樣,骨破壞的速度、程度、類型,局部因素消除情況: 菌斑、根分叉問題、咬合 牙松動(dòng) 余留牙的數(shù)目、分布； 患者依從性 環(huán)境與行為因素 全身、遺傳、年齡因素,牙周炎個(gè)別牙預(yù)后,探診深度、附著水平： 部位？程度？ 袋深淺不是決定的因素。 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：,牙周病治療計(jì)劃,總體目標(biāo),控制菌斑、炎癥 合理的牙周組織形態(tài) 糾正：牙周袋 齦退縮 骨缺損 牙松動(dòng) 牙齒及鄰接關(guān)系,恢復(fù)牙周組織功能合理的咬

3、合關(guān)系修復(fù)失牙戒除不良習(xí)慣,維持長期療效防復(fù)發(fā) 口腔衛(wèi)生指導(dǎo)與菌斑控制 定期檢查,治療程序,主要分為四個(gè)階段,第一階段病因治療,基礎(chǔ)治療 INITIAL THERAPY 消除、控制：致病因素 臨床炎癥,包括下列方法：,自我控制菌斑的方法： 刷牙方法和習(xí)慣； 牙線和牙簽； 菌斑顯示劑檢查 漱口劑,拔除病牙,潔治、刮治、根面平整術(shù) 藥物控制感染 咬合調(diào)整,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46周再評(píng)估，確認(rèn) 療效、依從性、治療方案,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,牙周手術(shù)目的,清除袋內(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

4、3月全面評(píng)估,手術(shù)的種類,牙齦切除術(shù) 切除肥大增生的牙齦 病理性牙周袋,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),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23月進(jìn)行 松牙固定 義齒修復(fù)、正畸,第四階段療效維護(hù)期,1st階段后無論是否需要進(jìn)行2、3階段治療即應(yīng)當(dāng)開始，內(nèi)容包括：,定期復(fù)查,時(shí)間：一般36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)因素：吸煙、全身疾病,復(fù)治,根據(jù)發(fā)現(xiàn)的問題進(jìn)行新一輪的治療與療效維護(hù),牙周治療與院內(nèi)感染,P163-164自學(xué),OVERTHANKS,牙周治療與院內(nèi)

5、感染交叉感染 是醫(yī)院內(nèi)感染(NOSOCOMIAL INFECTION)中的重要內(nèi)容之一。,醫(yī)院感染的傳播途徑有：,直接接觸病損、血液、體液、齦溝液、菌斑等； 吸人含致病菌的氣霧或飛濺物(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)供水管道中的存水返流人口中。,我國人群中HBV攜帶者約占10%，艾滋病、梅毒等也有增多的趨勢(shì)。,牙周診室控制感染特點(diǎn)及原則,病史采集及必要的檢查重視詢問全身疾病、傳染性疾病。“一致對(duì)待”原則universal precaution即假定每位患者均有血源性傳播的感染性疾病，診治中一律嚴(yán)格防交叉感染，必要時(shí)作有關(guān)的化驗(yàn)檢查。,治療器械的消毒 按器

6、械分類、分別用不同的方法消毒。 “雙消毒”：對(duì)使用過的器械應(yīng)實(shí)行消毒液浸泡、超聲波或手工清洗、清水沖凈干燥、高壓滅菌或其他消毒方法。大型設(shè)備如綜合治療臺(tái)表面等，可用可靠的消毒劑進(jìn)行表面擦拭等。,應(yīng)盡量使用已消毒的一次性用品(如檢查器、吸唾器、注射器等)。一人一機(jī)。也可2%碘酊擦拭手機(jī)的各部位，酒精脫碘2次，也可用1%碘附消毒。,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，污染的手套不得任意觸摸周圍的物品，治療結(jié)束后應(yīng)清洗手套上的血污后再摘除手套，書寫病歷等。,盡量使用腳控開關(guān)來調(diào)節(jié)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

7、要的銷毀。,減少治療椅周圍空氣中的細(xì)菌量治療前1%過氧化氫或0.12%氯己定液鼓漱一分鐘，減少患者口中的細(xì)菌數(shù)量、治療時(shí)的氣霧污染。診室內(nèi)應(yīng)有良好的通風(fēng)。不在診室內(nèi)飲水和進(jìn)食。,治療臺(tái)水管系統(tǒng)的消毒、阻止水回流的裝置；在每位患者治療結(jié)束后，再空放水30秒；每天開始工作前再?zèng)_水一至數(shù)分鐘。國外建議超聲波潔牙機(jī)使用單獨(dú)的凈水儲(chǔ)水器，并每周用1:10的次氯酸鈉液沖儲(chǔ)水系統(tǒng)，隨后立即用蒸餾水沖洗。,嚴(yán)格遵守控制醫(yī)院感染的原則，使病原微生物的擴(kuò)散和環(huán)境的污染降低到最小的程度。保護(hù)患者和醫(yī)務(wù)人員的利益安全。,Treatment can alter prognosis.,Prognosis has diff

8、erent connotations and nuances.,The patient has every right to know the answers to these questions.,Question？,Is my disease fatal?Will I lose my teeth?Will your treatment help me?What can you do to help me?,What are the therapeutic odds?What are the financial risks? What are the chances that the tre

9、atment will be of benefit?,Prognosis has three meanings in dentistry.,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?,Therapeutic prognosis.,Given the state of the art and sc

10、ience of periodontics and the knowledge and skill of the practitioner, what effect will periodontal treatment have on the course of the disease?,Prosthetic prognosis.,What is the forecast for the success of the prosthetic restoration? Will the prosthesis be therapeutic or detrimental? What specific

11、needs dictate that it be prescribed?,Judgement of the severity depends on ：,1. pocket depth, 2. degree of bone loss, 3. tooth mobility, 4. crown-root ratio.,generalized or localized,The distribution of disease： Inflammatory factors ： Traumatic factors：,Individual tooth therapeutic prognosis,includes

12、 such factors as ： Percentage of bone loss; Probing depth;,Distribution and type of bone lossPresence and severity of furcation involvementsMobility,Crown-root ratioPulpal involvementTooth position and occlusalStrategic value,Following are factors included in overall prognosis:,Age Medical status,In

13、dividual tooth prognoses (distribution and severity)Degree of involvement, duration, and history of the disease (rate of progression),Patient cooperationEconomic considerationsKnowledge and ability of the dentistEtiologic factors,Accuracy and completeness of the information gathered at the examinati

14、onDentists ability to recognize and eliminate or control the factors causing the disease,the patients ability and determination in maintaining the health of the periodontium and teeth.,The overall prognosis depends on the prognoses of the individual teeth.,PAST HISTORY (RATE OF DESTRUCTION),Probably

15、 the most important factor in forecasting the future health status of a dentition is knowledge of its past health status.,Speed of breakdown under controls or uncontrols The location, shape and depths of the pockets,Tooth mobility can be controlled or eliminated, the prognosis is better.The greater

16、the bone loss, the poorer the prognosis.,As bone loss exceeds 50%, the prognosis worsens rapidly.The more irregular the bone loss, the poorer the prognosis.,the pattern of bone loss: horizontal, vertical or infrabony defects.the age of the patient and the etiologic factors involved in the patients d

17、isease.,poorer prognosis: tilted, drifted, or rotated, hygiene difficult, elimination of pockets impaired,periodontal disease is complicated by active systemic factors and traumatism,morphologic in nature and include the number and distribution of teeth, tooth morphology, furcation involvement.,Exte

18、nt 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.,Root length and crown-root ratio must be considered,Angulation of root spread. Health of neighboring teeth.,The number and distrib

19、ution of teeth presentcrown-root ratio,shape and number of the root,the height of the alveolar crestpersonal psychologic and sociologic, financial considerations.,OTHER CONSIDERATIONS IN ESTABLISHING PROGNOSIS,The performance of home care is acceptable and the caries incidence is low,the prognosis i

20、s better,The prime consideration is the preservation of the dentition as a functioning unit.,In some instancesthe extraction of a single tooth will make the whole situation untenable.In other situations isolated extractions will simplify the problem.,what is considered to be a hopeless tooth. This w

21、ill make treatment planning simpler.,the characteristics of hopeless periodontally involved teeth:,Associated with intractable pain relieved, massive infection reduced by extractionMobility beyond 3 degrees,Furcation involvement with little or no interradicularboneBone loss beyond the apexBone loss

22、to the apex on one side of the tooth,Generalized circumferential bone loss to within 3 mm of the apexPocket depth to the apex without pulpal involvementVertical cracks or fractures,Inaccessible perforations or accessory canalsNumber and position of remaining teeth precluding prostheticExtreme caries

23、 susceptibility,Objectivesof treatment,Treatment goals should be evaluated in every case.,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?,Can tooth be restored?Can the pati

24、ent tolerate the treatment?,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.,As definitive laboratory tests are developed to make diagnosis more accurate, and as further knowledg

25、e concerning the etiology and pathogenesis of periodontal diseases is developed, prognosis will change from a qualitative to a quantitative judgment.,TREATMENT PLAN,PresentationPatient consentOrder of treatmentPhase IPhases Il and IIIMaintenance therapyProsthetic prescription,Alternative treatment p

26、lansTreatment criteriaQuality of carePhilosophy of treatmentRecord keepingReferral,PresentationPatient consentAfter hearing the presentation, the patient must decide whether to undergo treatment.,PHASE I,First steps (The initial effort) should be directed toward the elimination of inflammation and t

27、he institution of a program of plaque control.,To reduce pocket depthTo minimize periodontal traumatismOrthodontics(may precede or follow any surgical interventions),Extractions(Teeth with hopeless prognoses)RestorationsUsually periodontal therapy should precede restorative interventions. the restor

28、ations should be temporary,The provisional splinting during the treatment period should be evaluated.,Scheduling of restorative treatment should be done according to the following general rules:,Normal patients. (Restorative treatment starts immediately.)Class I (ADA periodontal disease classificati

29、on),Without occlusal treatment needCaries control and scaling and root planning. including plaque control, may be simultaneous. Definitive restorative treatment should follow completion of scaling and plaque control.,With occlusal treatment need Definitive restorative treatment may immediately follo

30、w completion of scaling, plaque control, and occlusal adjustment.,With surgical treatment need Definitive restorative treatment should not be instituted for at least 4 to 6 weeks after the patient has healed.,Splinting(Wire ligation and composite acid-etch splinting)Emergency (pain, swelling, infect

31、ion, and discomfort)The emergencies all take priority over other treatment scheduling.,Medical status a systemic condition that would complicate treatment, a medical consultation is necessary.,PHASES II AND III,Phase II surgery permits pocket elimination / reduction The restoration of normal osseous

32、 form ostectomy-osteoplastyosseous surgery combined with grafting procedures,root resectionsmucogingival and gingivectomyperiodontal-endodontic restorative treatmentprovisional splinting.,Maintenance therapyThe specialist may see the patient once a year or every other year for the less involved case

33、s, whereas the generalist maintains the patient in the recall system. Advanced cases may be seen alternately at 2- to 4-month intervals.,PROSTHETIC PRESCRIPTIONWaiting for a period of at least 2 months after periodontal surgery.Partial dentures or a fixed prosthesis,ALTERNATIVE TREATMENT PLANS,Alter

34、native treatment plans should be prepared for the patient who elects to forego splinting and surgery when these are indicated.,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 rigor

35、ous maintenance schedule with scaling and planing performed more frequently than is otherwise usual.,Treatment criteria,Quality of careIn general, periodontal care seeks the following:Removal of known etiologic factorsReduction of all pockets to a minimal depth to facilitate maintenance by the patie

36、nt and the dental hygienistCreation of a maintainable gingival and osseous architecture,Restoration of a functional and esthetic dentitionMaintenance of the resulting health by the patient, doctor, and hygienist,PHILOSOPHY OF TREATMENT,periodontal diseases can be treated successfully the health of t

37、he diseased periodontium can be restored and the teeth maintained.,The therapeutic concept of today includes all forms of therapy, conservative and complex selected and blended for the successful management of the individual patient.,Therapy must be tailored to the needs, both physical and psycholog

38、ic, of the patient.,RECORD KEEPINGThe treatment performed should be recorded carefully at each visit.,ReferralThere are three basic reasons for referral:(1) professional, (2) moral an ethical, and (3) legal.,Professional: Professional referrals are classified as follows:1. Medical:Referral/consultat

39、ion 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.,2.Dental: Referral/consultation is indicated when the dentist cannot provide the entire dental therapy

40、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.,3.Moral and ethical:,The specialists or consulting dentists upon completion of their care shall return the patien