1、QUESTION？Is my disease fatal?Will I lose my teeth?Will your treatment help me?What can you do to help me?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PROGNOSISPrognosisForecast预后预后预测预测预预 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有全
2、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后单纯性龈炎：良好单纯性龈炎：良好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2.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
3、.患者依从性患者依从性6.环境与行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：牙周病治疗计划牙周病治疗计划总体目标总体目标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损 牙松动牙松动牙齿及邻接关系
4、牙齿及邻接关系3.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治疗程序治疗程序主要分为四个阶段主要分为四个阶段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2.拔除病牙拔除病牙3.洁治、刮
5、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6.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手术目的牙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手术的种类手术的种类1.牙龈切除术牙龈切除术切除
6、肥大增生的牙龈病理性牙周袋2.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、正畸第四阶段第四阶段疗效维护期疗效维护期1st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：1.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、
7、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2.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治疗与院内感染牙周治疗与院内感染P163-164自学自学OVERTHANKS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。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
8、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。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。牙周诊室控制感染牙周诊室控制感染特点及原则特点及原则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
9、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。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。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
10、、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。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。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
11、械及覆盖一次性器械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。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。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；每天开始工作前再冲水一至数分
12、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。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。Treatment can alter prognosis.Prognosis has different connotations and nuance
13、s.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 treatment will be of benefit?Prognosi
14、s 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 nowWhat is the anticipated future of these teeth?Therapeutic prognosis.Given the state of the art and science of periodontics and the knowledge a
15、nd 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 needs dictate that it be prescribed?Judgement
16、of the severity depends on：1.pocket depth,2.degree of bone loss,3.tooth mobility,4.crown-root ratio.generalized or localizedThe distribution of disease：Inflammatory factors：Traumatic factors：Individual tooth therapeutic prognosisincludes such factors as：Percentage of bone loss;Probing depth;Distribu
17、tion and type of bone lossPresence and severity of furcation involvementsMobilityCrown-root ratioPulpal involvementTooth position and occlusalStrategic valueFollowing are factors included in overall prognosis:AgeMedical statusIndividual tooth prognoses (distribution and severity)Degree of involvemen
18、t,duration,and history of the disease(rate of progression)Patient cooperationEconomic considerationsKnowledge and ability of the dentistEtiologic factorsAccuracy and completeness of the information gathered at the examinationDentists ability to recognize and eliminate or control the factors causing
19、the diseasethe 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 the most important factor in forecasting the future health status of a dentition
20、is knowledge of its past health status.Speed of breakdown under controls or uncontrols The location,shape and depths of the pocketsTooth mobility can be controlled or eliminated,the prognosis is better.The greater the bone loss,the poorer the prognosis.As bone loss exceeds 50%,the prognosis worsens
21、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 disease.poorer prognosis:tilted,drifted,or rotated,hygiene difficult,elimination of pockets im
22、pairedperiodontal disease is complicated by active systemic factors and traumatismmorphologic in nature and include the number and distribution of teeth,tooth morphology,furcation involvement.Extent of involvement.Is the furcation partially or totally involved?Status of bone support.If the bone leve
23、ls are relatively sound,the effort to save may be justifiable.Root length and crown-root ratio must be consideredAngulation of root spread.Health of neighboring teeth.The number and distribution of teeth presentcrown-root ratio,shape and number of the root the height of the alveolar crestpersonal ps
24、ychologic and sociologic,financial considerations.OTHER CONSIDERATIONS IN ESTABLISHING PROGNOSISThe performance of home care is acceptable and the caries incidence is low,the prognosis is better The prime consideration is the preservation of the dentition as a functioning unit.In some instancesthe e
25、xtraction 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 will make treatment planning simpler.the characteristics of hopeless periodontally involved teeth:Associated with intr
26、actable pain relieved,massive infection reduced by extractionMobility beyond 3 degreesFurcation involvement with little or no interradicularboneBone loss beyond the apexBone loss to the apex on one side of the toothGeneralized circumferential bone loss to within 3 mm of the apexPocket depth to the a
27、pex without pulpal involvementVertical cracks or fracturesInaccessible perforations or accessory canalsNumber and position of remaining teeth precluding prostheticExtreme caries susceptibilityObjectivesof treatmentTreatment goals should be evaluated in every case.Can treatment objectives of a firm n
28、on-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 patient tolerate the treatment?If you believe the answers to these questions to be yes,then plan and proceed with the treatment.If“no,
29、”alternative treatment,compromise,or extraction is advisable.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
30、judgment.TREATMENT PLANPresentationPatient consentOrder of treatmentPhase IPhases Il and IIIMaintenance therapyProsthetic prescriptionAlternative treatment plansTreatment criteriaQuality of carePhilosophy of treatmentRecord keepingReferralPresentationPatient consentAfter hearing the presentation,the
31、 patient must decide whether to undergo treatment.PHASE IFirst steps(The initial effort)should be directed toward the elimination of inflammation and the institution of a program of plaque control.To reduce pocket depthTo minimize periodontal traumatismOrthodontics(may precede or follow any surgical
32、 interventions)Extractions(Teeth with hopeless prognoses)RestorationsUsually periodontal therapy should precede restorative interventions.the restorations should be temporaryThe provisional splinting during the treatment period should be evaluated.Scheduling of restorative treatment should be done a
33、ccording to the following general rules:Normal patients.(Restorative treatment starts immediately.)Class I(ADA periodontal disease classification)Without occlusal treatment needCaries control and scaling and root planning.including plaque control,may be simultaneous.Definitive restorative treatment
34、should follow completion of scaling and plaque control.With occlusal treatment need Definitive restorative treatment may immediately follow completion of scaling,plaque control,and occlusal adjustment.With surgical treatment need Definitive restorative treatment should not be instituted for at least
35、 4 to 6 weeks after the patient has healed.Splinting(Wire ligation and composite acid-etch splinting)Emergency(pain,swelling,infection,and discomfort)The emergencies all take priority over other treatment scheduling.Medical status a systemic condition that would complicate treatment,a medical consul
36、tation is necessary.PHASES II AND IIIPhase II surgery permits pocket elimination/reduction The restoration of normal osseous form ostectomy-osteoplastyosseous surgery combined with grafting proceduresroot resectionsmucogingival and gingivectomyperiodontal-endodontic restorative treatmentprovisional
37、splinting.Maintenance therapyThe 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.PROSTHETIC PRESCRIPTIONWaiting for a period o
38、f at least 2 months after periodontal surgery.Partial dentures or a fixed prosthesis ALTERNATIVE TREATMENT PLANSAlternative 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 t
39、herapy 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.Treatment criteriaQuality of careIn general,periodontal care seeks the following:Remo
40、val of known etiologic factorsReduction of all pockets to a minimal depth to facilitate maintenance by the patient and the dental hygienistCreation of a maintainable gingival and osseous architectureRestoration of a functional and esthetic dentitionMaintenance of the resulting health by the patient,
41、doctor,and hygienistPHILOSOPHY OF TREATMENTperiodontal diseases can be treated successfully the health of the 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
42、 management of the individual patient.Therapy must be tailored to the needs,both physical and psychologic,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
43、.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.2.Dental:Refe
44、rral/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 patie
45、nts 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 patient,unless the patient expressly reveals a different preference,to the referring dentist,or if none,to the dentist of recor
46、d for future care.The specialists shall be obligated when there is no referring dentist and upon a completion of their treatment to inform patients when there is a need for further dental care.Other reasons for referral include:patient relocation,dentist-patient personality conflict,and dentists pre
47、ference.Some dentists do not use specialty,do not use specialty service CommunicationInforming the patient about the disease condition;a recall-maintenance schedule should be made.DocumentationAll communication,written or verbal,must be properly documented on the patients chart.Patients have the rig
48、ht of access to their records and may acquire copies of the original documents,not original documents.SummaryIt is difficult for the dentist or specialist to possess expert knowledge and skill in all areas of dentistry because of the ever-expanding scope and complexity of dental therapy.Todays denti
49、st is confronted with a wide range of treatment procedures and available alternatives.At all times during the course of treatment,the primary focus is the patients welfare.Effective communication and interaction among the dentist,the patient,and the specialist are vital elements of proper treatment.
