牙周病治療中心
牙周病治療

牙周病醫師的職責 Periodontal Treatment

牙周病的形成通常是非常慢性的,若無透過檢查通常是難以發現以至於造成日後的破壞。故醫師的檢查及預防是與治療有等同的效用。牙周的照護不是只給有牙周病的患者,健康的患者也等同重要。所謂預防勝於治療,初期的患者的治療不但較輕鬆簡單又可提早知道保健牙齒的照護知識。對於較嚴重的患者除了要對證下藥找到原因積極治療外,牙周病醫師也必須為日後的口腔環境製造較佳的清潔環境以幫助病人能夠輕鬆的維持。治療是針對每個病人不同的狀況而不同,同時也需要與各科專科醫師如贗復科,矯正科,根管治療科等等,以為病人制訂最好的治療計畫。治療項目有非手術性/手術性治療,植牙手術,牙脊增高術,牙冠增長術或軟組織手術移植以覆蓋牙根或增厚角化牙齦等。同樣的術後定期維持也是與治療等同重要。

 

何謂牙周病?What is periodontal disease?

牙周是牙齒周邊組織如牙齦,齒槽骨,牙周韌帶所形成以使牙齒能有正常功能咀嚼,維護牙齒健康及美觀。牙周一發炎是不容小覷,若不治療將導致日後假牙地基崩毀,牙齒鬆動至脫落。牙菌斑是最主要的原因,而牙菌斑的形成又是每分每秒都在口腔環境內發生。故口腔環境的維持仍是最主要的環節,但其他致病要素如不當假牙,齒列不整,咬合干擾,吸煙,糖尿病,賀爾蒙,營養及身體狀況等都會影響牙周的健康。

牙齦炎:較輕微僅局限於牙肉組織,治療與口腔衛生維護良好即可改善。原因如不良的口腔衛生,不合適的假牙,身體狀況,藥物,荷爾蒙等等都會影響牙肉組織的健康。

牙周病:通常是嚴重又無治療的牙齦炎所發展而來的。當牙周囊袋發展越深所形成的厭氧菌落往往造成身體嚴重發炎反應。所造成的破壞乃是齒槽骨破壞,牙齒鬆脫,口臭,膿包生成等等。病患在早期並無明顯症狀通常到後期才有明顯感覺。故定期的檢查是相當重要。早期發現的預後都相當良好,治療也越簡單輕鬆。嚴重的患者因多數牙齒鬆脫移位便需要較復雜的治療,如全口重建,植牙手術即相關的齒槽骨頭再生,鼻竇增高術等等。

近年研究也顯示牙周致病菌可經由血液循環至全身系統,可影響至心臟,肺臟等其他身體器官。與中風,心血管疾病,糖尿病,低體重出生嬰兒等有相關。

 

第一階段非手術性治療
Phase I-Initial Preparation ( non-surgical treatment)

輕度至中度的患者即囊袋深度較淺,通常非手術性治療即可有良好癒後。治療包括口腔衛教,牙齒表面清潔,牙結石刮除,牙根整平或合併抗生素治療以恢復牙周組織的健康。同時間也要檢查是否有咬合干擾,齒列不整,假牙合適等等並合併身體健康的情況。 此時病患的最終贗覆或矯正治療計畫應已擬定 。等到四到六週後再評估看是否須進入第二階段的治療,即所謂的手術治療—牙周再生手術,牙周翻瓣手術,齒槽骨再生手術,植牙手術,牙根覆蓋術等。

 

第二階段手術性治療
Phase II –Surgical Treatment

非手術性的治療對於較深囊帶效果有限,Stambaugh 提出牙周器械的有效深度小於4mm,而最大極限為5.3mm,再加上牙根結構的變異,多根牙根的清潔又因為牙根分岔而更加困難。故牙周手術是有其必要性以助清潔更可以明確知道骨頭缺損的狀況,以進行牙周再生手術或骨修磨手術達到減小囊袋的深度。此第二階段手術必須已知道最終治療計畫為原則,配合贗覆,矯正等他科的治療計畫再訂定適當的牙周或植牙手術計畫。


▲ 臼齒牙根形態變異多且器械清潔不易。

 

1.牙周再生手術
Regenerative Procedure

利用牙周再生膜以或牙釉質形成素併人工骨粉能促進牙周組織再生, 以重建牙周附連結締組織。


▲ 右下第一大臼齒遠心端角狀骨缺損


▲ 再生膜與骨粉放置在骨缺損處


▲ 術前與術後對照

 

2.牙根覆蓋術
Mucogingival Surgery (soft tissue augmentation/ Root coverage procedure)

已自體移植的上顎結締組織或人工組織皮質覆蓋牙根以達到增加組織厚度或是改善牙齦萎縮的程度。能改善程度因應牙周的破壞程度有關。


▲ 右上門齒至第一大臼齒間牙根覆蓋術,以上顎結締組織移植後覆蓋牙表面。


▲ 右下第一小臼齒至第一大臼齒區牙根暴露,以上顎結締組織移植後覆蓋牙表面。


▲ 左下第一門齒牙根暴露, 以上顎結締組織移植後覆蓋牙表面。


▲ (術中) 植體角化牙齦不足,以上顎角化牙齦移植以增厚植體牙肉組織厚度及角化程度,幫助日後植牙清潔維護。


▲ 術後一個月後牙肉組織修復情形。

 

3.牙冠增長術
Crown Lengthening Procedure

為提供製作假牙所需的牙齒結構所需要牙肉組織與齒槽骨修整的手術。


▲ 以假牙最後的外型當作模板,以修整牙肉及骨頭的關係,使最終假牙結構穩定以及有良好的軟組織外型。


▲ 修整牙肉與骨頭的位置以改善牙齒短小造成的笑齦,幫助病人有美麗的微笑。

 

4.人工植牙
Dental Implant Surgery

—將人工植體植入缺牙的齒槽骨待四到六個月以達骨整合,之後再將假牙接上植體,取代傳統牙橋需磨鄰接牙的缺點,也可取代活動假牙,增加病人的舒適感。但須經過軟組織以及硬組織的評估確定是否適合植牙或需重建牙脊等相關術式。


▲ 右上第二門牙因長期缺損已有齒脊凹陷的情況,以人工牙根合併骨頭/軟組織重建。 

術後牙脊外型以及牙肉外型均已修復,以達病人美觀要求。

 

5.牙脊重建
Ridge Augmentation (adding bone to the jaw)

因缺牙過久而造成牙脊的塌陷,此術式將利用可吸收或不可吸收再生膜及人工骨粉以引導骨頭再生成。

 

6.牙脊保存術
Ridge (socket) Preservation

研究顯示拔牙後三個月內骨吸收成度為最大量,為減緩拔牙後齒槽骨吸收過度而在拔牙同時放置骨粉及再生膜,以保存牙脊的高度及寬度。

 

7.鼻竇增高術
Sinus Bone Augmentation

在上顎後牙區因為拔牙後或缺牙過久將導致骨頭的嚴重吸收,鼻竇腔又通常在後牙牙根上方,所剩下的牙脊高度往往不夠植體的長度。故需經由鼻竇增高術—將鼻竇膜往上推所多出的空間將以人工骨粉填捕,待九個月後即可植牙。或若牙脊高度仍有5mm 以上,便可與植體手術同時進行。

▲ 左上牙脊嚴重吸收至鄰近鼻竇空間,將上顎鼻竇膜往上推並以人工骨粉製造出骨頭空間。術後為九個月後電腦斷層顯示。

 

Phase III-贗覆或矯正時期 Prosthetic/Orthodontal Treatment

在經過手術時期後,當病人的口腔衛生及牙周狀態穩定時,病人便可進入最後製作假牙或矯正階段。此時牙周病醫師還是得注意病人的情況尤其是在矯正時的口腔衛生及牙周情況,每二至三個月監控病人牙周情況。

 

Phase IV- 維持期 Maintenance

維持與治療視同同等重要。病人已經經過相當繁雜及耗時的治療,其成果的維持勢必須的,否則牙周病的復發是相當容易的。所以在贗復完成後,應當每三至六個月回診,其項目包括全口再檢查,X光片檢測,牙齦上下徹底清潔,氟化物治療以減少齲齒,牙根敏感的問題 。

 

 
Periodontal Treatment

What do periodontists do?

We provide the detection and prevention of periodontal disease as well as its treatments. “ Periodontal care” is required for healthy as well as diseased tissues. For patients without notable periodontal disease, “periodontal care” is a prophylactic (or preventative) measure. For patients with periodontal disease, it consists of effective treatment for the elimination of disease and the creation of conditions conducive to periodontal health. Treatments will be tailored to each patients needs using interdisciplinary approaches in coordination with other specialists. The procedures range from non-surgical to surgical periodontal treatments, implant surgery, and cosmetic procedures such as gum graft surgery (the addition of gum tissue), crown lengthening surgery (increase tooth length) , and ridge augmentation (the addition of bone to the jaw). Maintenance is as important as treatment itself.

What is periodontal disease?

In order to know what is periodontal disease, we need to understand what makes the periodontium. The periodontium consists of the tissue all around teeth, such as gum, bony structure and periodontal ligaments. All of which support the tooth in function, health and aesthetics. Periodontal disease, including gingivitis and periodontitis, are not minor infections. If left untreated, these infections can lead to tooth loss, bone deterioration and eventual destruction of the jaw. It is usually chronic in nature, beginning with the bacteria commonly known as plaque (the sticky, colorless films that constantly forms on the teeth).

Gingivitis—is the mildest form of periodontal disease. The gum tissue will become red, swollen, and bleed easily. It is caused by inadequate oral hygiene and also some local factors such as ill-fitting crowns or can be caused by some hormone and systemic conditions. However, the disease is reversible with professional treatment and good oral hygiene.

If left untreated, gingivitis can advance to periodontitis. Periodontitis consists of bacterial toxins that stimulate chronic inflammation. This inflammation can lead to the breaking down of supporting tissues and eventually bone destruction. Periodontal pockets form and create space between the teeth and gums. As these pockets become deeper, bacterial pathogens thrive and become more aggressive. Often times, the destructive process has mild symptoms. Therefore, it is not uncommon for patients to not be aware of the problem until their symptoms occur as pain, gum enlargement, excessive gum bleeding, tooth loosening and/or tooth migration.

Signs and Symptoms-

  1. Swollen gum tissue
  2. Bright red or purplish gum tissue
  3. Gum recession
  4. Lesions of the gum tissue resulting in the formation of pus
  5. Bad breath (chronic halitosis)
  6. Bad taste in your month
  7. Loose teeth
  8. Tooth migration or change of the bite
  9. Tooth loss

Research suggests that the periodontal pathogens can be inhaled or enter to your bloodstream through your gum tissue, affecting lungs, heart and other parts of your body. This can lead to more serious conditions.

Phase I-Initial Preparation ( non-surgical treatment)

Usually very effective in slight to moderate periodontitis. The treatment includes:

  1. Supra/subgingival scaling (a full cleaning of the tooth structure)
  2. Root planning
  3. Adjunctive antibiotic (local application or systemic distribution of antibiotics) 
  4. Occlusion Analysis, selective occlusal adjustment (bite adjustment)
  5. Interdepartmental Consultation-Endodontists, Orthodontists, Prosthodontists
  6. Eliminating local factors: removing faulty restorations, Root canal retreatment, restoration of decayed areas (cavities filling)
  7. Systemic health / nutrition evaluation and consultation
  8. Phase I re-evaluation

Phase II –Surgical Treatment

Research has shown that non-surgical treatment (as mentioned above) has its limitations, especially for the teeth with pocket depths more than 5mm. Hand instruments efficiency is less than 4mm, and the limitation is about 5.52mm. Also, multi-rooted teeth (such as molars) are more difficult to access in terms of the anatomy of the roots, than single-rooted teeth (such as canines). Therefore, surgical treatments provide accessibility and precision in the detection of bony defects for regenerative and pocket reduction procedures. To assure a good result, a definitive prosthetic treatment plan will be provided prior to surgical treatment to cooperate with crown lengthening, soft/hard tissue augmentation and implant surgeries.

Regenerative Procedure

Using resorbable (self-dissolving) and non-resorbable (manually removed) membrane combined with allograft (human bone material) or xenograft (bovine bone material) to maintain the space for future new bone growth.

Mucogingival Surgery (soft tissue augmentation/ Root coverage procedure)

Using allograft or autograft from the hard palate connective, tissue is transferred to the exposed root sites or the deficient ridge (thin jaw bone) to cover the root. Thickening the tissue size and providing more keratinized tissue is necessary

Crown Lengthening Procedure

(Usually combined with the patient’s prosthetic treatment plan) Using the provisional crowns to re-create sufficient tooth structure and reshape the bone to have a better soft tissue profile around new prosthesis

Dental Implant Surgery

A dental implant is placed into the missing tooth area for 4-6 months to allow for ossteointegration (allowing the implant to directly connect with the bone). The procedure can be performed in a one-staged or two-staged approach depending on the bone augmentation needed or not.

Ridge Augmentation (adding bone to the jaw)

(Usually needed in severe atrophy ridges.) Guided bone regeneration will be performed with non-resorbable or resorbable membranes and allograft/xenograft bone materials.

Ridge (socket) Preservation

After tooth extraction, 2/3 of bone resorption occurs within the first 3 months. Therefore, resorbable membrane and bone graft materials can be placed to decrease the rate of the resorption and preserve the ridge morphology.

Sinus Bone Augmentation

Upper posterior teeth roots are located adjacent to the sinus floor. Severe ridge deficiency is often found after tooth extraction. Dental implants or the allograft/xenograft materials are used to provide space in the sinus cavity for bone regeneration.

 

Prosthetic/Orthodontal Treatment

After the surgical phase, the patient’s oral hygiene and the periodontal condition should be stable and ready for any following prosthetic or orthodontal treatment. However, during this period, the patient‘s condition should be also monitored every 2-3 months (or less) depending on the patient’s oral hygiene.

Maintenance

Maintenance is as important as the treatment itself. Patients should be examined every 3 months or 6 months depending on their condition and prior treatment. Follow up treatment should include thorough examination, radiographs, supra/sub-gingival cleaning, and fluoride treatment.