RU2231318C1 - Method for treating the cases of rapid progressive periodontitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves diagnosing, healing the oral cavity, administering antibiotic therapy, splinting teeth, surgically treating periodontal pockets with tooth radices, all bone defects of alveolar process to be filled with transplant being concurrently treated and suturing periodontal tissues next to it. Deproteinized spongious bone gel 3A is used as transplant. Secondary adentia being the case, prosthetics is applied with removable temporary prostheses being used. Secondary occlusion deformity being the case, medical splinting with bracket system applied is carried out before performing surgical treatment. Surgical treatment of periodontal pockets, all bone defects of alveolar process, periapical lesions and withdrawing teeth of the third motility degree is carried out applying simultaneous operation on the whole jaw at the same time. The treated periodontal pockets, all bone defects of alveolar process, periapical lesions and withdrawn teeth sockets are completely filled with transplant.

EFFECT: rapid arrest of disease progressive development; repaired alveolar process structure.

5 cl

Description

The invention relates to medicine, more specifically to dentistry, and can be used to treat rapidly progressive periodontitis. The problem of treating patients with rapidly progressive periodontitis (BPP) is that with this disease there is a rapid destruction of the bone within 3-5 years in patients with an average age of 15 to 40 years. This disease in the clinic is represented by a juvenile form (localized and generalized), as well as rapidly progressive periodontitis in adults. The clinic of this pathology develops either acutely (complaints of a general and local nature are expressed: hyperemia and swelling of the gums, pronounced tooth mobility, the presence of periodontal pockets of various depths, plentiful or slight dental deposits; the disease is often accompanied by fever, general malaise, often depression and weight loss ), or asymptomatically (for the first time, patients pay attention to increasing mobility and tooth displacement). The result of this process is an early progressive multiple tooth loss, malocclusion, a decrease in the height of the alveolar ridge in areas of secondary adentia, which not only leads to early removable prosthetics, but also complicates the latter.

Therefore, reconstructive surgery using various grafts occupies a special place in the treatment of BPP. The selection of materials is determined by the following requirements - osteoinduction, osteoconduction, the absence of side effects and complications, biological compatibility, rapid healing and speed of bone structure restoration, ease of use. The currently widespread use of synthetic materials is sometimes not entirely justified. The restructuring of synthetic materials is slow, and often they play the role of simply filling the bone cavities with a slight degree of bone regeneration and adversely affect the formation of the surrounding bone. Possible complications when using synthetic materials may lead to the need to remove not only the material, but also the part of the bone surrounding the graft.

A known method of treatment of rapidly progressive periodontitis, including diagnosis, oral sanitation, antibiotic therapy, splinting of teeth, surgical treatment of periodontal pockets with the treatment of tooth roots, all bone defects of the alveolar bone filled with a graft, and subsequent suturing of periodontal tissues (RF patent, No. 2150903, cl. A 61 B 17/24, publ. 2000).

The use of a synthetic graft implies a relatively slow bone remodeling, which is quite dangerous for tooth loss with a bone index (CP) = 0-1, in addition, a synthetic graft requires a good saturation with a blood clot when used, otherwise the bone remodeling process does not occur in the pathological focus , but even when dissolved in a blood clot, it does not hold its shape, which does not provide a vertical increase in bone tissue and a corresponding decrease in gum recession;

- splinting, semi-permanent (glaspan) + heliocomposite or permanent (solid cast structures are removable or non-removable) immediately before or after surgery creates a rigid block that causes periodontal overload and enhances, in turn, tissue resorption in the area of the splinted tooth block, and it is enhanced in the postoperative period;

- with secondary partial adentia, a decrease in the height of the bite often occurs and traumatic occlusion occurs, which increases the trauma of the periodontium;

repeated surgical operations in patients with various periodontal pathologies enhance their psychological and physical injuries (repeated operations lead to multiple scars of the gingival margin, an increase in the number of medications, an increase in the treatment period, etc.), which often leads to an interruption in the intended course of treatment.

The objective of the present invention is to develop a method for treating BPP, which provides a quick stop to the development of the disease, its stabilization, full restoration of the structure of the alveolar bone of the jaw within the bone defects of any etiology (periodontal bone pockets, alveoli previously removed or removed during surgery, teeth, cystic cavities).

The technical result consists in increasing the effectiveness of treatment by creating a wider range of bacteriologically inactive flora, facilitating the excision of not only the affected and granulating gum tissues, but also altered tissues in the area of the holes of previously extracted teeth and teeth directly removed during surgery, more rapid healing, reduction the timing of the formation of bone tissue with a bone index of 1, reducing the time of regeneration of bone tissue due to good adhesion of the material to the tissues, high osteoconductively sti and osteoinductance of the material, providing a more long-term remission of the pathological process.

The result is achieved in that in the method of treatment of rapidly progressive periodontitis, including diagnosis, oral rehabilitation, antibiotic therapy, splinting of the teeth, surgical treatment of periodontal pockets with the treatment of the roots of the teeth, all bone defects of the alveolar process, filled with the graft, and subsequent suturing of the periodontal tissues, prosthetics with using temporary removable prostheses, conduct medical splinting using a bracket system, carry out surgical treatment okolover khushnyh foci and tooth extraction with a third degree of mobility, a new bioactive osteoplastic material is used as a graft, and the fact that the surgical treatment of periodontal pockets, all bone defects of the alveolar bone, peri-apical foci and teeth of the third degree of mobility is carried out by using simultaneous surgery on the entire jaw immediately and by the fact that treated periodontal pockets, all bone defects of the alveolar ridge, near-apical foci and holes of the extracted teeth lnyayut bioactive osteoplastic material completely.

The method is implemented as follows.

Before the operation, the patient is examined, oral sanitation and correction of fillings, professional hygiene; with secondary adentia, temporary prostheses are made; with secondary deformation of the bite, medical splinting of the teeth with a bracket system is performed; conduct a course of antibiotic therapy, preliminary selective grinding and then surgical treatment; after medical splinting, splinting of the teeth is carried out with semi-permanent or permanent fixed structures and splinting prosthetics (dentures that, in addition to restoring missing teeth, splint the remaining ones and thereby distribute the load across the entire dentition, it is best to use arch prosthetics for BPPV). At the same time, at the first stage of treatment, temporary splinting (beam, ligature tires with the use of composite materials), selective grinding, removal of dental plaque are performed. Selective grinding is carried out in several visits under the control of occludograms and analysis of jaw models.

When removing dental plaque, thorough treatment of all surfaces of the teeth with the help of excavators, hooks, curettes, burs, ultrasounds Piezon Master (EMS company) is necessary, after which grinding and polishing of the neck of the teeth using various rubber cups, heads, strips, polishing pastes, followed by coating of the necks of teeth with fluorine varnish.

The success of complex treatment depends on the quality of the hygiene measures carried out not only at the doctor's office, but also at home.

Claforan antibiotic is administered, 1.0 (g) is diluted in 3 ml of 0.5% novocaine solution or water for injection and is administered intramuscularly 2 times a day, the course of administration of the drug is 5 days. But at the same time, the spectrum of action of the antibiotic locally in the wound (for 20 days) was expanded by using three types of antibiotics in the transplant: cytran, reflin, diflucan. As a transplant, deproteinized cancellous bone gel 3A (DPGC - gel 3A) is used. Graft composition: deproteinized spongy bone allogeneic or xenogenic, ground into flour, the product of collagen hydrolysis and three antibiotics (tsifran, reflin, diflucan). A 0.3 g tablet is stored at t = -20 ° C for a year.

Before surgical treatment in the presence of secondary deformities of the occlusion and tooth mobility, it is rational to use a bracket system to splint and restore the correct occlusal relationships.

In areas of secondary adentia, removable prosthetics are used, replacing dentition defects up to 6 teeth and allowing to restore the correct occlusal ratio, thereby eliminating the injury to the remaining group of teeth.

Then carry out surgical treatment.

Surgical treatment is carried out against the background of the above administration of claforan. At the stage of surgical treatment, a flap operation using the Ramfjord technique is used, for which three horizontal incisions are made: scalloped, retreating 0.5-1 mm of the gingival margin and repeating the gingival contour at an angle of 35 ° to the tooth (splitting of the flap is carried out and the technique is simplified since a new gingival margin is created with a clean wound surface without a stage of de-epithelialization), bordering an incision around each tooth in the surgical area and interdental in the anteroposterior direction under the gum papillae. These incisions create remodeling of the gingival margin, preserving the sparing state of the inner surface of the flap without significant injury to the periosteum. A thorough curettage is carried out, the affected and granulation tissues, subgingival dental deposits and altered root cement are removed with careful grinding and polishing, processing of the alveolar bone tissue using the Piezon-Master ultrasonic device from EMS. If there are not only periodontal bone pockets, but also near-apical foci, if it is necessary to remove teeth with a third degree of mobility, at the same time (the term means the consistent use of various therapeutic measures in one patient during one visit, the need for which is dictated by a combination of different pathologies in one patient and the desire to eliminate the foci of bone tissue infection within one visit) conduct all types of surgical operations aimed at eliminating foci of inf projections in the bone tissue followed by plastic bone defects: in the presence of near-apical foci, the flap in the area of individual teeth is simultaneously raised to the projection of the root tips, granulation is removed, the cortical plate is opened with a milling cutter, the root tips are carefully excised, cystectomy is performed (cyst removal), bone curettage antiseptic treatment with 3% hydrogen peroxide solution and 1% iodinol solution; in the presence of mobile teeth (with the third degree), the latter are simultaneously removed with subsequent plastic surgery of the alveoli (holes).

DPGC - 3A gel is placed into bone defects, completely filling them and sealing with a sterile gauze swab, while the material is well saturated with a blood clot.

In the presence of near-apical foci or bone pockets communicating with the maxillary sinus, surgical treatment of the wound and plastic surgery of the defect are performed, without waiting for the material to dissolve in the blood clot, which prevents its excess from entering the maxillary sinus. The material in the solid state is placed in the defect in one portion and compacted once with a sterile gauze swab under a slight pressure of the instrument (subsequent compressions are undesirable). The wound is sutured in the interdental spaces until a snug fit of the mucosal-periosteal flap.

After 7 days, the stitches are removed. On the 7th day, normalization of the general condition, the absence of soft tissue edema and temperature reaction are observed. Locally, slight hyperemia (redness) and moderate swelling of the gums are observed, the sutures are wealthy, there is no discharge from the wound.

On the 12th day, there is a stabilization of the process and the absence of edema, the beginning of epithelialization, a decrease in the pathological mobility of the teeth. Rampfjord patchwork without the use of a graft leads to a remission of the process, where reduction of tooth mobility and their stabilization are possible, however, bone tissue growth after a year was not observed in these patients.

Rampfjord patchwork using synthetic grafts (hydroxyappatite ceramics, etc.) allows filling in bone defects, but according to X-ray diffraction data, hydroxyappatite granules are not replaced by bone tissue after one year.

Rampfjord patchwork using a valve increases the effective treatment of BPP, creating bone growth over a period of 6 to 12 months.

After filling the bone pockets and bone peri-apical foci with the preparation of DPGK - gel 3A, the process of bone formation is radiologically observed after one month, and after 3 months a clear radiological pattern of the new bone tissue is noted.

In the area of bone grafting of the holes, the formation of the bone structure is observed almost over the entire height of the hole, the contours of the previously extracted tooth disappear. After 3 months, the bone contour of the tissue in the area of the holes is identical to the bone contour of a healthy periodontium.

The use of DPGK - gel 3A reduces the time of restoration of the bone structure in bone defects, bringing the bone architectonics closer to normal. After treatment, patients visit the doctor after one, and then every three months during the first year to assess the clinical condition of periodontal disease, preventive measures (professional hygiene, airborne roots), which reduces the risk of reinfection. Once a year, X-ray control (OPTMG) is performed and a bone index is determined - KP (percentage of safety and percentage loss of bone tissue).

When performing osteoplasty, CP (according to x-ray data) changes: an increase in CP indicates bone growth, or remains unchanged, which indicates the stabilization of the process.

In the process of observation, according to indications, selective grinding of teeth is carried out. After the restoration of the correct occlusal relationships is completed, the teeth are splintered with semi-permanent or permanent structures and, in the presence of secondary adentia, the treatment is completed with clasp prosthetics, which excludes trauma and periodontal overload.

In the process of observation, professional hygiene is periodically carried out with grinding and polishing of the necks of the teeth according to indications, selective grinding and repeated surgical intervention in separate areas against the background of mandatory antibiotic therapy.

Early splinting of the teeth is extremely important, as the reserve capacity of the periodontium is reduced. It should be noted that splinting of teeth can be carried out both before and after surgery. With the resorption of the alveolar process of the periodontium and the destruction of the connective epithelium, the periodontal endurance potential is greatly reduced. Recovery of masticatory function, redistribution of masticatory pressure, elimination of the traumatic effect of premature contacts. As a result of subsequent splinting of teeth, the conditions for periodontal functioning are significantly improved. If we are talking about the destruction of bone tissue at the level of 1/2 roots and the mobility is slightly expressed, we can recommend fixed splinting structures with the replacement of individual teeth. In case of more pronounced resorption and mobility, it is advisable to perform splinting with more rigid solid cast removable structures, use beam tires in the front section, use tapes with permanent fixation by helio-composite materials for a greater cosmetic effect and stabilization of teeth. Given the vulnerability of periodontal tissues, these patients should undergo orthopedic treatment that excludes injury and periodontal compression.

Clinical examples

1. Patient I., 42 years old, complained of constant purulent discharge in the area of the 35 tooth, fistulous passage in the projection of the top of the tooth from the lingual side, displacement and mobility of the teeth, bad breath. In the anamnesis: bleeding of gums worries for more than ten years, tooth displacement occurs gradually, changing the appearance of the patient, earlier periodontal disease has not been treated. Objectively during examination, there is observed: partial secondary adentia of the upper and lower jaw, deformation of the dentition (fan-shaped divergence of teeth, medial slope 23, 37), hyperemia, swelling of the mucosa, supragingival and subgingival tartar, ZDK (tooth-gingival pockets) from 4 to 10 mm (norm 2 mm), PN 2 (Pisarev-Schiller test, indicates the degree of inflammation of the gingival margin, normal - 0 points no inflammation), PI - 6.6 (periodontal index, indicates the prevalence and intensity of periodontal tissue damage; periodontal condition of each tooth appreciate from 0 to 8, taking into account the degree of gingival inflammation, tooth mobility, depth of ZDK; norm 0), KP - 0.65 (bone index, indicates the percentage of bone tissue), mobility of 35 tooth - third degree, 35 tooth - intact, periodontal cyst in region 35, small vestibule of the lower jaw. According to x-ray (OPTMG - orthopantomogram and visiography), a mixed type of bone resorption is determined, in the region of the apex of the 35 tooth root - bone resorption is 5.3 - 6.2 mm, bone density is 0 (determined according to the visiograph in arbitrary units from 0 - no bones up to 128, etc., the upper boundary is individual). Diagnosed with rapidly progressive periodontitis in adults of severe degree. Comprehensive treatment was carried out, including professional hygiene, antibiotic therapy, endodontic treatment of 35 teeth, temporary removable prosthetics, orthodontic treatment + selective grinding, periodontal surgery in the area of the teeth of the upper and lower jaw (patch operation using the Ramfjord technique + osteoplasty with DPAH-3 graft. After 8-10 days, there was no inflammation, suppuration, tightening of the gingival margin, no pain when biting on a 35 tooth after 10 days, X-ray after 1 m a month there is a formation of the structure of the interroot partitions and a new bone in the region of the 35 tooth, after 4 months the density of the bone structure in the region of the 35 tooth approaches the norm - 165 (the norm of healthy bone is 185), in the region of the previously healthy bone the density increased from 185 to 209, after 11 months - alignment of occlusal contacts.

2. Patient K., 35 years old, came to the clinic with complaints of a fistula, swelling of the gums in the area of 41 teeth, mobility 31, 42 of the first degree, 41 of the third degree, bleeding of the gums when brushing, bad breath; the purpose of the visit is to prepare for prosthetics. From the anamnesis of the disease: tooth mobility has been disturbing for several years, previously teeth were removed due to not only destruction, but also mobility. So on 01.07.1999, the clinic removed the 36th tooth (third degree) in the clinic, after the removal of the plastic of the well of DPHC - gel 3A was simultaneously performed. Objectively: insufficient hygiene, tooth mobility of 1-3 degrees, over and subgingival tartar, partial secondary adentia, the bite on the right is not fixed; 18, 17, 16, 41 teeth - Popov-Godon phenomenon (teeth extended), proinence (extension) 41 tooth, fan-shaped divergence of the teeth of the upper jaw; the gingival margin is edematous, hyperemic, fistulous passage in the region of 41 teeth, transitional fold in the region of the anterior teeth of the lower jaw is smoothed, painful on palpation, ZDK tooth gingival pockets from 3 to 8 mm, PS - Pisarev-Schiller test from 1 to 3 points, PI - periodontal index of 8 points, CP in the area of 41 teeth 0 points.

The patient was examined, periodontal status was examined, the diagnosis was made: BPV, a treatment plan was drawn up, including oral sanitation, professional hygiene, braces splinting, antibiotic therapy, osteoplasty in the upper and lower jaw (patchwork using the Ramfjord technique and simultaneously extraction of teeth with a third degree of mobility and subsequent plastic bone defects and holes) material DPGK-gel 3A. After removing the bracket system, the teeth were splinted with 34, 33, 32, 31, 41, 42, 43, 44 with glassspan and heliocomposite material.

For this period, stable stabilization of the process was observed: the gum is pale pink, dense, lack of ZDK, the hygiene level is good, the occlusal contacts are aligned, the tremors and diastema of the upper jaw are closed, the teeth were moved vertically to normal.

According to x-ray data 1: 07/01/99 in the area of the 36 tooth, complete resorption of the bone at the medial root, KP - 0 - this is a picture before the removal of the 36 tooth, on the day of removal and plasty of the socket; November 24, 1999, in the area of the previously removed tooth, the borders of the dimples are practically not contoured, the vertical bone growth, the bone structure is determined radiologically.

According to x-ray data 2 (11/19/1999 - before treatment, 11/24/00 - at the time of surgery, 12/01/00 - 1 month after the operation, 03/03/01 - four observations in a period of 3.5 months in tooth region 41 tooth transition is observed from 0 to 1-2, the tooth is introduced into the occlusal curve, the formation of bone tissue in the area of the vertical bone defect 41 tooth.

The patient is referred to an orthopedic surgeon for further prosthetics. Thus, the invention allows to increase the effectiveness of treatment by creating a wider range of bacteriologically inactive flora, facilitating excision of not only affected and granulating gum tissues, but also altered tissues in the region of the holes of previously extracted teeth and directly removed teeth during the operation, more accelerated healing, reduction of bone formation time with bone index 1, reduction of bone tissue regeneration due to good adhesion of the material to tissues, high osteoconduction ivnosti osteoinductivity material and providing a long-term remission of the pathological process by splinting braces systems and eliminating secondary deformation.

Claims (5)

1. A method for the treatment of rapidly progressive periodontitis, including diagnostics, oral sanitation, antibiotic therapy, splinting of teeth, surgical treatment of periodontal pockets with treatment of tooth roots, all bone defects of the alveolar bone filled with a graft, and subsequent suturing of periodontal tissues, characterized in that as a graft use deproteinized cancellous bone - gel 3A. 2. The method according to claim 1, characterized in that in the case of secondary adentia prior to surgical treatment, prosthetics are performed using temporary removable dentures. 3. The method according to claim 1, characterized in that in the presence of secondary deformation of the bite before surgical treatment, medical splinting is performed using a bracket system. 4. The method according to claim 1, characterized in that the surgical treatment of periodontal pockets, all bone defects of the alveolar ridge, peri-apical foci and tooth extraction of the third degree of mobility is carried out by using simultaneous surgery and on the entire jaw immediately. 5. The method according to claim 1, characterized in that the treated periodontal pockets, all bone defects of the alveolar ridge, peri-apical foci and holes of the extracted teeth are completely filled with bioactive bone-plastic material.