1、牙周病的预后和计划牙周病的预后和计划第第 11 章章 PROGNOSTIC JUDGMENT TREATMENT PLANNING牙周病的预后和计划牙周病的预后和计划牙周病的预后和计划2PROGNOSISPrognosisForecast预后预后预测预测牙周病的预后和计划3预预 后后 类类 型型骨吸收骨吸收 病病 因因 依从性依从性 全身病变全身病变极佳极佳无无可消除可消除良好良好无无良好良好轻轻较差较差中中难消除难消除差差明显明显/未控制未控制极差极差重重牙周病的预后和计划4牙周病的预后和计划5有全身因素的牙龈炎有全身因素的牙龈炎全身因素控制后可以痊愈全身因素控制后可以痊愈龈炎的预后龈炎的预
2、后单纯性龈炎：良好单纯性龈炎：良好牙周病的预后和计划6牙周炎的预后牙周炎的预后总预后总预后个别牙预后个别牙预后牙周病的预后和计划7牙周炎总预后牙周炎总预后对整个牙列预后的评估，内容包括对整个牙列预后的评估，内容包括1.牙周炎的类型牙周炎的类型单因素轻中度单因素轻中度CP，疗效易巩固疗效易巩固有全身因素的牙周炎，变化多样有全身因素的牙周炎，变化多样牙周病的预后和计划82.骨破坏的速度、程度、类型骨破坏的速度、程度、类型 3.局部因素消除情况局部因素消除情况:菌斑、根分叉问题、咬合菌斑、根分叉问题、咬合3.牙松动牙松动4.余留牙的数目、分布；余留牙的数目、分布；5.患者依从性患者依从性6.环境与行
3、为因素环境与行为因素7.全身、遗传、年龄因素全身、遗传、年龄因素牙周病的预后和计划9牙周炎个别牙预后牙周炎个别牙预后1.探诊深度、附着水平：探诊深度、附着水平：部位？程度？部位？程度？袋深浅不是决定的因素。袋深浅不是决定的因素。2.牙槽骨：牙槽骨：破坏部位、程度、根分叉病变；破坏部位、程度、根分叉病变；3.牙松动度：牙松动度：自限性？进行性牙松动？自限性？进行性牙松动？4.牙解剖：牙解剖：牙周病的预后和计划10牙周病治疗计划牙周病治疗计划牙周病的预后和计划11总体目标总体目标1.控制菌斑、炎症控制菌斑、炎症2.合理的牙周组织形态合理的牙周组织形态纠正：牙周袋纠正：牙周袋 龈退缩龈退缩骨缺损骨缺
4、损 牙松动牙松动牙齿及邻接关系牙齿及邻接关系牙周病的预后和计划123.恢复牙周组织功能恢复牙周组织功能合理的咬合关系合理的咬合关系修复失牙修复失牙戒除不良习惯戒除不良习惯4.维持长期疗效防复发维持长期疗效防复发口腔卫生指导与菌斑控制口腔卫生指导与菌斑控制定期检查定期检查牙周病的预后和计划13治疗程序治疗程序主要分为四个阶段主要分为四个阶段牙周病的预后和计划14第一阶段第一阶段病因治疗病因治疗基础治疗基础治疗INITIAL THERAPY消除、控制：消除、控制：致病因素致病因素临床炎症临床炎症牙周病的预后和计划15包括下列方法：包括下列方法：1.自我控制菌斑的方法：自我控制菌斑的方法：刷牙方法和
5、习惯；刷牙方法和习惯；牙线和牙签；牙线和牙签；菌斑显示剂检查菌斑显示剂检查漱口剂漱口剂牙周病的预后和计划162.拔除病牙拔除病牙3.洁治、刮治、根面平洁治、刮治、根面平整术整术4.药物控制感染药物控制感染5.咬合调整咬合调整牙周病的预后和计划176.治疗龋齿，矫正不良治疗龋齿，矫正不良修复体和食物嵌塞修复体和食物嵌塞7.处理牙周处理牙周-牙髓病变牙髓病变1st阶段结束后阶段结束后46周再评估，确认周再评估，确认疗效、依从性、治疗方案疗效、依从性、治疗方案牙周病的预后和计划18第二个阶段第二个阶段牙周手术治疗牙周手术治疗并非每个患者都要进行并非每个患者都要进行牙周病的预后和计划19牙周手术目的牙
6、周手术目的清除袋内感染物清除袋内感染物根面平整根面平整治疗牙槽骨缺损治疗牙槽骨缺损纠正龈及膜龈畸形纠正龈及膜龈畸形基础治疗后基础治疗后13月全面评估月全面评估牙周病的预后和计划20手术的种类手术的种类1.牙龈切除术牙龈切除术切除肥大增生的牙龈病理性牙周袋牙周病的预后和计划212.翻瓣术翻瓣术3.牙周骨手术牙周骨手术骨修整术、植骨4.GTR5.膜龈手术膜龈手术6.牙种植术牙种植术牙周病的预后和计划22第三阶段第三阶段修复治疗阶段修复治疗阶段并非每个患者都要进行2st阶段后阶段后23月进行月进行松牙固定松牙固定义齿修复、正畸义齿修复、正畸牙周病的预后和计划23第四阶段第四阶段疗效维护期疗效维护期1
7、st阶段后无论是否需要进行阶段后无论是否需要进行2、3阶段治疗即应当开始，内阶段治疗即应当开始，内容包括：容包括：牙周病的预后和计划241.定期复查定期复查1.时间：一般时间：一般36个月个月1次。次。2.内容：内容：PLI、CI、DI、GI、BOP、PD、附着水平、牙松动度、附着水平、牙松动度、咬合情况、骨高度、密度、咬合情况、骨高度、密度、危险因素：危险因素：吸烟、全身疾病吸烟、全身疾病牙周病的预后和计划252.复治复治根据发现的问题进行新根据发现的问题进行新一轮的治疗与疗效维护一轮的治疗与疗效维护牙周病的预后和计划26牙周治疗与院内感染牙周治疗与院内感染P163-164自学自学牙周病的预
8、后和计划27OVERTHANKS牙周病的预后和计划28牙周治疗与院内感染牙周治疗与院内感染交叉感染交叉感染 是医院内感染是医院内感染(NOSOCOMIAL INFECTION)中的重要内容之一。中的重要内容之一。牙周病的预后和计划29医院感染的传播途径有：医院感染的传播途径有：直接接触直接接触病损、血液、体液、龈沟液、菌斑等；病损、血液、体液、龈沟液、菌斑等；吸人吸人含致病菌的气雾或飞溅物含致病菌的气雾或飞溅物(如血液、唾液等如血液、唾液等)；间接接触间接接触(污染器械、手、治疗台等传染媒体污染器械、手、治疗台等传染媒体)；手机手机供水管道中的存水返流人口中。供水管道中的存水返流人口中。牙周病
9、的预后和计划30我国人群中我国人群中HBV携带者约占携带者约占10%，艾滋病、梅毒等也有增多的趋势。艾滋病、梅毒等也有增多的趋势。牙周病的预后和计划31牙周诊室控制感染牙周诊室控制感染特点及原则特点及原则牙周病的预后和计划32病史采集及必要的检查病史采集及必要的检查重视询问全身疾病、传染性疾病。重视询问全身疾病、传染性疾病。“一致对待一致对待”原则原则universal precaution即假定每位患者均有血源性传播的感染性疾病，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，必要时作有关的诊治中一律严格防交叉感染，必要时作有关的化验检查。化验检查。牙周病的预后和计划33
10、 治疗器械的消毒治疗器械的消毒 按器械分类、分别用不同的方法消毒。按器械分类、分别用不同的方法消毒。“双消毒双消毒”：对使用过的器械应实行消毒液：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。菌或其他消毒方法。大型设备大型设备如综合治疗台表面等，如综合治疗台表面等，可用可靠的消毒剂进行表面擦拭等。可用可靠的消毒剂进行表面擦拭等。牙周病的预后和计划34应尽量使用已消毒的一次性用品应尽量使用已消毒的一次性用品(如检查器、吸唾器、注射器等如检查器、吸唾器、注射器等)。一人一机。一人一机。也可也可2%碘酊擦拭手机的各
11、部位，酒精脱碘碘酊擦拭手机的各部位，酒精脱碘2次，次，也可用也可用1%碘附消毒。碘附消毒。牙周病的预后和计划35保护性屏障保护性屏障口罩、帽子、防护眼镜、面罩、手套、工作服等口罩、帽子、防护眼镜、面罩、手套、工作服等治疗过程中，治疗过程中，污染的手套不得任意触摸周围的物品，污染的手套不得任意触摸周围的物品，治疗结束后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。应清洗手套上的血污后再摘除手套，书写病历等。牙周病的预后和计划36尽量使用尽量使用脚控开关来调节治疗椅脚控开关来调节治疗椅照明灯扶手、开关等可用一次性照明灯扶手、开关等可用一次性覆盖物覆盖。覆盖物覆盖。一次性器械及覆盖一次性器械
12、及覆盖物在用毕后应妥善、单独回收，物在用毕后应妥善、单独回收，作必要的销毁。作必要的销毁。牙周病的预后和计划37减少治疗椅周围空气中的细菌量减少治疗椅周围空气中的细菌量治疗前治疗前1%过氧化氢或过氧化氢或0.12%氯己定液鼓漱氯己定液鼓漱一分钟，减少患者口中的细菌数量、治疗时的一分钟，减少患者口中的细菌数量、治疗时的气雾污染。气雾污染。诊室内应有良好的诊室内应有良好的通风通风。不在诊室内饮水和进食。不在诊室内饮水和进食。牙周病的预后和计划38治疗台水管系统的消毒、治疗台水管系统的消毒、阻止水回流的装置；阻止水回流的装置；在每位患者治疗结束后，再空放水在每位患者治疗结束后，再空放水30秒；秒；每
13、天开始工作前再冲水一至数分钟。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国外建议超声波洁牙机使用单独的净水储水器，并每周用水器，并每周用1:10的次氯酸钠液冲储水的次氯酸钠液冲储水系统，随后立即用蒸馏水冲洗。系统，随后立即用蒸馏水冲洗。牙周病的预后和计划39严格遵守控制医院感染的原则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使病原微生物的扩散和环境的污染降低到最小的程度。降低到最小的程度。保护患者和医务人员的利益安全。保护患者和医务人员的利益安全。牙周病的预后和计划40Treatment can alter prognosis.Prognosis ha
14、s different connotations and nuances.The patient has every right to know the answers to these questions.牙周病的预后和计划41Question？Is my disease fatal?Will I lose my teeth?Will your treatment help me?What can you do to help me?牙周病的预后和计划42What are the therapeutic odds?What are the financial risks?What are t
15、he chances that the treatment will be of benefit?牙周病的预后和计划43Prognosis has three meanings in dentistry.牙周病的预后和计划44Diagnostic prognosis.What are evaluations of the course of the disease without treatment?What is the status of the teeth nowWhat is the anticipated future of these teeth?牙周病的预后和计划45Therap
16、eutic 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?牙周病的预后和计划46Prosthetic prognosis.What is the forecast for the success of the prosthetic restoration?Will the
17、prosthesis be therapeutic or detrimental?What specific needs dictate that it be prescribed?牙周病的预后和计划47Judgement of the severity depends on：1.pocket depth,2.degree of bone loss,3.tooth mobility,4.crown-root ratio.牙周病的预后和计划48generalized or localizedThe distribution of disease：Inflammatory factors：Trau
18、matic factors：牙周病的预后和计划49Individual tooth therapeutic prognosisincludes such factors as：Percentage of bone loss;Probing depth;牙周病的预后和计划50Distribution and type of bone lossPresence and severity of furcation involvementsMobility牙周病的预后和计划51Crown-root ratioPulpal involvementTooth position and occlusalSt
19、rategic value牙周病的预后和计划52Following are factors included in overall prognosis:AgeMedical status牙周病的预后和计划53Individual tooth prognoses (distribution and severity)Degree of involvement,duration,and history of the disease(rate of progression)牙周病的预后和计划54Patient cooperationEconomic considerationsKnowledge a
20、nd ability of the dentistEtiologic factors牙周病的预后和计划55Accuracy and completeness of the information gathered at the examinationDentists ability to recognize and eliminate or control the factors causing the disease牙周病的预后和计划56the patients ability and determination in maintaining the health of the period
21、ontium and teeth.牙周病的预后和计划57The overall prognosis depends on the prognoses of the individual teeth.牙周病的预后和计划58PAST HISTORY(RATE OF DESTRUCTION)牙周病的预后和计划59Probably the most important factor in forecasting the future health status of a dentition is knowledge of its past health status.牙周病的预后和计划60Speed
22、of breakdown under controls or uncontrols The location,shape and depths of the pockets牙周病的预后和计划61Tooth mobility can be controlled or eliminated,the prognosis is better.The greater the bone loss,the poorer the prognosis.牙周病的预后和计划62As bone loss exceeds 50%,the prognosis worsens rapidly.The more irregu
23、lar the bone loss,the poorer the prognosis.牙周病的预后和计划63the pattern of bone loss:horizontal,vertical or infrabony defects.the age of the patient and the etiologic factors involved in the patients disease.牙周病的预后和计划64poorer prognosis:tilted,drifted,or rotated,hygiene difficult,elimination of pockets imp
24、aired牙周病的预后和计划65periodontal disease is complicated by active systemic factors and traumatism牙周病的预后和计划66morphologic in nature and include the number and distribution of teeth,tooth morphology,furcation involvement.牙周病的预后和计划67Extent of involvement.Is the furcation partially or totally involved?Status
25、of bone support.If the bone levels are relatively sound,the effort to save may be justifiable.牙周病的预后和计划68Root length and crown-root ratio must be considered牙周病的预后和计划69Angulation of root spread.Health of neighboring teeth.牙周病的预后和计划70The number and distribution of teeth presentcrown-root ratio,shape a
26、nd number of the root 牙周病的预后和计划71the height of the alveolar crestpersonal psychologic and sociologic,financial considerations.牙周病的预后和计划72OTHER CONSIDERATIONS IN ESTABLISHING PROGNOSIS牙周病的预后和计划73The performance of home care is acceptable and the caries incidence is low,the prognosis is better 牙周病的预后和
27、计划74The prime consideration is the preservation of the dentition as a functioning unit.牙周病的预后和计划75In some instancesthe extraction of a single tooth will make the whole situation untenable.In other situations isolated extractions will simplify the problem.牙周病的预后和计划76what is considered to be a hopeles
28、s tooth.This will make treatment planning simpler.牙周病的预后和计划77the characteristics of hopeless periodontally involved teeth:牙周病的预后和计划78Associated with intractable pain relieved,massive infection reduced by extractionMobility beyond 3 degrees牙周病的预后和计划79Furcation involvement with little or no interradic
29、ularboneBone loss beyond the apexBone loss to the apex on one side of the tooth牙周病的预后和计划80Generalized circumferential bone loss to within 3 mm of the apexPocket depth to the apex without pulpal involvementVertical cracks or fractures牙周病的预后和计划81Inaccessible perforations or accessory canalsNumber and
30、position of remaining teeth precluding prostheticExtreme caries susceptibility牙周病的预后和计划82Objectivesof treatment牙周病的预后和计划83Treatment goals should be evaluated in every case.牙周病的预后和计划84Can treatment objectives of a firm non-retractable gingiva that does not bleed be reached?Can the pocket be eliminate
31、d?Will the bone regenerate?Can the tooth be stabilized?牙周病的预后和计划85Can tooth be restored?Can the patient tolerate the treatment?牙周病的预后和计划86If 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 advisabl
32、e.牙周病的预后和计划87As 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.牙周病的预后和计划88TREATMENT PLAN牙周病的预后和计划89Pre
33、sentationPatient consentOrder of treatmentPhase IPhases Il and IIIMaintenance therapyProsthetic prescription牙周病的预后和计划90Alternative treatment plansTreatment criteriaQuality of carePhilosophy of treatmentRecord keepingReferral牙周病的预后和计划91PresentationPatient consentAfter hearing the presentation,the pat
34、ient must decide whether to undergo treatment.牙周病的预后和计划92PHASE I牙周病的预后和计划93First steps(The initial effort)should be directed toward the elimination of inflammation and the institution of a program of plaque control.牙周病的预后和计划94To reduce pocket depthTo minimize periodontal traumatismOrthodontics(may p
35、recede or follow any surgical interventions)牙周病的预后和计划95Extractions(Teeth with hopeless prognoses)RestorationsUsually periodontal therapy should precede restorative interventions.the restorations should be temporary牙周病的预后和计划96The provisional splinting during the treatment period should be evaluated.牙
36、周病的预后和计划97Scheduling of restorative treatment should be done according to the following general rules:牙周病的预后和计划98Normal patients.(Restorative treatment starts immediately.)Class I(ADA periodontal disease classification)牙周病的预后和计划99Without occlusal treatment needCaries control and scaling and root pla
37、nning.including plaque control,may be simultaneous.Definitive restorative treatment should follow completion of scaling and plaque control.牙周病的预后和计划100With occlusal treatment need Definitive restorative treatment may immediately follow completion of scaling,plaque control,and occlusal adjustment.牙周病
38、的预后和计划101With surgical treatment need Definitive restorative treatment should not be instituted for at least 4 to 6 weeks after the patient has healed.牙周病的预后和计划102Splinting(Wire ligation and composite acid-etch splinting)Emergency(pain,swelling,infection,and discomfort)The emergencies all take prior
39、ity over other treatment scheduling.牙周病的预后和计划103Medical status a systemic condition that would complicate treatment,a medical consultation is necessary.牙周病的预后和计划104PHASES II AND III牙周病的预后和计划105Phase II surgery permits pocket elimination/reduction The restoration of normal osseous form ostectomy-oste
40、oplastyosseous surgery combined with grafting procedures牙周病的预后和计划106root resectionsmucogingival and gingivectomyperiodontal-endodontic restorative treatmentprovisional splinting.牙周病的预后和计划107Maintenance therapyThe specialist may see the patient once a year or every other year for the less involved ca
41、ses,whereas the generalist maintains the patient in the recall system.Advanced cases may be seen alternately at 2-to 4-month intervals.牙周病的预后和计划108PROSTHETIC PRESCRIPTIONWaiting for a period of at least 2 months after periodontal surgery.Partial dentures or a fixed prosthesis 牙周病的预后和计划109ALTERNATIVE
42、 TREATMENT PLANS牙周病的预后和计划110Alternative treatment plans should be prepared for the patient who elects to forego splinting and surgery when these are indicated.牙周病的预后和计划111In this case the patient may be treated through phase I therapy and be placed on a maintenance schedule.The establishment of an a
43、lternative plan generally calls for a rigorous maintenance schedule with scaling and planing performed more frequently than is otherwise usual.牙周病的预后和计划112Treatment criteria牙周病的预后和计划113Quality of careIn general,periodontal care seeks the following:Removal of known etiologic factorsReduction of all p
44、ockets to a minimal depth to facilitate maintenance by the patient and the dental hygienistCreation of a maintainable gingival and osseous architecture牙周病的预后和计划114Restoration of a functional and esthetic dentitionMaintenance of the resulting health by the patient,doctor,and hygienist牙周病的预后和计划115PHIL
45、OSOPHY OF TREATMENT牙周病的预后和计划116The therapeutic concept of today includes all forms of therapy,conservative and complex selected and blended for the successful management of the individual patient.牙周病的预后和计划118Therapy must be tailored to the needs,both physical and psychologic,of the patient.牙周病的预后和计划
46、119RECORD KEEPINGThe treatment performed should be recorded carefully at each visit.牙周病的预后和计划120ReferralThere are three basic reasons for referral:(1)professional,(2)moral an ethical,and(3)legal.牙周病的预后和计划121Professional:Professional referrals are classified as follows:1.Medical:Referral/consultation
47、 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.牙周病的预后和计划1222.Dental:Referral/consultation is indicated when the dentist cannot provide the entire dental t
48、herapy 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.牙周病的预后和计划1233.M
49、oral and ethical:The specialists or consulting dentists upon completion of their care shall return the patient,unless the patient expressly reveals a different preference,to the referring dentist,or if none,to the dentist of record for future care.牙周病的预后和计划124The specialists shall be obligated when
50、there is no referring dentist and upon a completion of their treatment to inform patients when there is a need for further dental care.牙周病的预后和计划125Other reasons for referral include:patient relocation,dentist-patient personality conflict,and dentists preference.Some dentists do not use specialty,do
