郭忠軍，李瑞春，韓鳳琴，陳 芳

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單純牙周翻瓣術(shù)和牙周翻瓣術(shù)前行牙周非手術(shù)治療對(duì)重度牙周炎的療效比較

郭忠軍1，李瑞春1，韓鳳琴1，陳 芳2

目的 比較單純牙周翻瓣術(shù)和牙周翻瓣術(shù)前行牙周非手術(shù)治療兩種方法治療重度牙周炎的療效。方法 本臨床試驗(yàn)共納入了28例重度牙周炎患者，隨機(jī)分入實(shí)驗(yàn)組和對(duì)照組(每組14例)。對(duì)照組患者直接行改良的牙周翻瓣術(shù)；實(shí)驗(yàn)組患者接受牙周非手術(shù)治療后行改良的牙周翻瓣術(shù)。納入時(shí)及納入后3、6個(gè)月檢查并記錄所有受試者的牙周探診出血(bleeding on probing， BOP)、牙周探診深度(pocket probing depth，PPD)、臨床附著水平(clinical attachment lose，CAL)及牙槽骨水平(level of bone，LOB)。采用t檢驗(yàn)及χ2檢驗(yàn)對(duì)結(jié)果進(jìn)行比較分析。結(jié)果 與納入時(shí)相比，經(jīng)過(guò)牙周治療后，兩組患者的BOP、PPD、 CAL均有顯著改善；兩組對(duì)比，納入時(shí)無(wú)明顯差異；6個(gè)月后進(jìn)行復(fù)查時(shí)，實(shí)驗(yàn)組的牙周探診深度的降低顯著高于對(duì)照組[(4.0±0.23)mmvs(4.9±0.13)mm,P<0.01]，臨床附著水平的改善也優(yōu)于對(duì)照組[(5.6±0.30)mmvs(5.5±0.29) mm,P<0.01]。結(jié)論 牙周翻瓣術(shù)前對(duì)重度牙周炎患者行牙周非手術(shù)治療可以在一定程度上提高牙周手術(shù)治療的效果。

重度牙周炎；牙周翻瓣術(shù)；臨床附著水平

牙周炎是牙周微生物引發(fā)的牙齒支持組織的免疫和炎性狀態(tài)。牙周組織和免疫系統(tǒng)的相互作用導(dǎo)致慢性炎性、連接組織的破壞及牙槽骨的吸收[1]，牙周炎不僅會(huì)造成口腔局部的損害[2-5]，而且對(duì)全身的其他疾病也有影響[6-10]。治療牙周炎的原則是清除附著在牙齒及牙周組織的菌斑、牙石、色素等刺激物，主要包括非手術(shù)治療及手術(shù)治療。牙周非手術(shù)治療主要指口腔健康宣教、口腔衛(wèi)生指導(dǎo)、潔治術(shù)和刮治術(shù)[11,12]；牙周手術(shù)治療主要是牙周翻瓣術(shù)。對(duì)于輕中度牙周炎，牙周非手術(shù)治療一般可以取得較滿意的效果[13,14]，但是對(duì)于中重度牙周炎，則多數(shù)不能達(dá)到治療要求[15-17]。為了克服非手術(shù)治療的局限性，現(xiàn)多采用直接行翻瓣術(shù)的方法治療重度牙周炎。迄今為止，關(guān)于結(jié)合牙周非手術(shù)與手術(shù)方法治療牙周炎的效果的研究還比較少，筆者對(duì)比了單純牙周手術(shù)治療與牙周手術(shù)結(jié)合牙周非手術(shù)治療后，重度牙周炎患者的恢復(fù)情況，以期為臨床治療牙周炎提供相關(guān)參考。

1 對(duì)象與方法

1.1 對(duì)象 2015-02至2015-11于陜西省渭南市中心醫(yī)院口腔科就診的符合納入條件的共28例重度牙周炎患者，在知情同意的情況下加入本研究，并簽署了知情同意書(shū)，所有患者經(jīng)常規(guī)齦上潔治及拋光術(shù)后2周，進(jìn)行全口牙周相關(guān)指數(shù)檢查，包括：探診出血(bleeding on probing，BOP)、探診深度(pocket probing depth，PPD)、附著水平(clinical attachment lose，CAL)、牙槽骨水平(level of bone，LOB)，符合納入標(biāo)準(zhǔn)的患者被隨機(jī)分為實(shí)驗(yàn)組和對(duì)照組，每組14例，實(shí)驗(yàn)組為行翻瓣手術(shù)前進(jìn)行了非手術(shù)治療，對(duì)照組為僅進(jìn)行常規(guī)翻瓣術(shù)。納入標(biāo)準(zhǔn)：18歲以上；至少3顆相鄰的牙齒患有重度牙周炎(探診深度≥7 mm，附著喪失≥4 mm)；未患影響牙周健康及愈合的系統(tǒng)性疾??；能進(jìn)行較好的菌斑控制；能按照試驗(yàn)要求按時(shí)復(fù)診。排除標(biāo)準(zhǔn)為：吸煙；妊娠期或哺乳期婦女；過(guò)去3個(gè)月服用過(guò)抗生素或非甾體類抗炎藥；過(guò)去兩年內(nèi)接受過(guò)牙周系統(tǒng)治療(包括非手術(shù)及手術(shù))。

1.2 治療方法 所有患者首次就診時(shí)接受詳細(xì)的全口牙周檢查、口腔衛(wèi)生指導(dǎo)、X線檢查及潔治術(shù)。牙周檢查所包括的指標(biāo)有：每顆牙齒6個(gè)位點(diǎn)(近頰、頰側(cè)正中、遠(yuǎn)頰、近舌、舌側(cè)正中、遠(yuǎn)舌)的BOP、PPD、CAL、LOB，這也是評(píng)價(jià)及比較牙周治療術(shù)后療效的主要變量。選取符合條件的相鄰3顆牙齒作為治療區(qū)，對(duì)實(shí)驗(yàn)組進(jìn)行齦上下刮治術(shù)和根面平整，對(duì)照組行改良的牙周翻瓣術(shù)。2個(gè)月后對(duì)實(shí)驗(yàn)組患者的治療區(qū)再評(píng)估后實(shí)施翻瓣術(shù)。患者納入3個(gè)月和6個(gè)月后，再次檢查并記錄所有受試者的牙周相關(guān)指標(biāo)。

1.3 各指標(biāo)測(cè)量方法 (1)BOP：使用Hu-Friedy 牙周探針進(jìn)行探診，觀察15 s后有出血?jiǎng)t記為陽(yáng)性，計(jì)算結(jié)果為每顆牙齒平均出血位點(diǎn)數(shù)。(2)PPD：齦緣至牙周袋底的距離。(3)CAL：釉牙骨質(zhì)界至牙周袋底的距離。(4)LOB：釉牙骨質(zhì)界至牙槽嵴頂?shù)木嚯x。

1.4 統(tǒng)計(jì)學(xué)處理 運(yùn)用SPSS 19.0 統(tǒng)計(jì)軟件對(duì)試驗(yàn)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析。使用兩樣本t檢驗(yàn)或配對(duì)樣本t檢驗(yàn)比較。兩樣本率的比較運(yùn)用χ2檢驗(yàn)的方法。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié) 果

實(shí)驗(yàn)組與對(duì)照組所納入患者的年齡、性別組成及治療前的牙周主要指標(biāo)相近，差異無(wú)統(tǒng)計(jì)學(xué)意義(表1)。

比較指標(biāo)實(shí)驗(yàn)組對(duì)照組χ2/tP年齡(歲)41.1±2.2540.6±2.710.7230.475男/女7/78/60.1440.705BOP(個(gè))5.0±0.895.2±0.940.3670.721PPD(mm)7.5±0.457.2±0.441.3460.208CAL(mm)7.1±0.336.7±0.232.2030.061LOB(mm)2.8±0.272.5±0.311.6290.131

注：實(shí)驗(yàn)組指翻瓣術(shù)前進(jìn)行非手術(shù)治療；對(duì)照組指僅進(jìn)行翻瓣術(shù)；BOP.探診出血；PPD.牙周探診深度；CAL.臨床附著水平；LOB.牙槽骨水平

表2顯示了受試者納入3個(gè)月和6個(gè)月時(shí)牙周主要指標(biāo)與治療前的對(duì)比情況。結(jié)果顯示，經(jīng)過(guò)治療后，無(wú)論實(shí)驗(yàn)組還是對(duì)照組，牙周狀況都有顯著改善，表現(xiàn)為探診出血位點(diǎn)變低、探診深度減少、臨床附著水平增加(因牙槽骨水平在整個(gè)實(shí)驗(yàn)階段未發(fā)生顯著變化，其相關(guān)數(shù)據(jù)并未在本文列出)，且實(shí)驗(yàn)組牙周狀況好于對(duì)照組。

表2 兩組重度牙周炎患者治療后3個(gè)月、 6個(gè)月BOP、PPD、CAL的變化 (n=14；

注：實(shí)驗(yàn)組指翻瓣術(shù)前進(jìn)行非手術(shù)治療；對(duì)照組指僅進(jìn)行翻瓣術(shù)；BOP.探診出血；PPD.牙周探診深度；CAL.臨床附著水平；與治療前相比，①P<0.05，②P<0.01；與對(duì)照組比較，③P<0.05,④P<0.01

3 討 論

本試驗(yàn)主要比較了單純牙周手術(shù)治療與牙周手術(shù)結(jié)合牙周非手術(shù)治療后，重度牙周炎患者的平均BOP位點(diǎn)數(shù)、PPD、CAL、LOB的變化情況，發(fā)現(xiàn)除牙槽骨水平外，兩種方法治療后都可以一定程度上使相關(guān)臨床指標(biāo)得到明顯的改善，但是后者更加顯著。治療前，各指標(biāo)雖然無(wú)統(tǒng)計(jì)學(xué)差異，但是實(shí)驗(yàn)組的PPD、CAL的平均值高于對(duì)照組，因此兩種治療方法所產(chǎn)生的差異可能更加明顯。在此研究中，實(shí)驗(yàn)組的患者取得更滿意的治療效果，其中部分原因可能是該組患者在接受牙周基礎(chǔ)治療的過(guò)程中得到了更加頻繁的口腔衛(wèi)生指導(dǎo)和維護(hù)，但這種因素所起的作用有多大，現(xiàn)在還無(wú)從得知。以往有一些研究對(duì)比了單純牙周非手術(shù)治療與牙周手術(shù)治療的療效，發(fā)現(xiàn)牙周手術(shù)治療更有利于重度牙周炎患者的病情控制[18]。考慮到牙周基礎(chǔ)治療的局限性，當(dāng)重度牙周炎患者前來(lái)就診時(shí)，口腔醫(yī)生可能更傾向于做出直接行牙周手術(shù)的治療建議，但是本文所得到的試驗(yàn)結(jié)果值得臨床醫(yī)師的思考，如果兩種方式相結(jié)合更有利于治療牙周炎，那么在行牙周手術(shù)治療前行牙周非手術(shù)治療未嘗不可，且可能有一部分位點(diǎn)經(jīng)基礎(chǔ)治療后癥狀明顯改善而不需后續(xù)的手術(shù)治療，從而避免相關(guān)并發(fā)癥。

在此項(xiàng)研究中，3個(gè)月、6個(gè)月后進(jìn)行的兩組間比較和治療后與治療前的比較都未發(fā)現(xiàn)牙槽骨水平有顯著變化，可能是由于觀察時(shí)間較短的緣故，這也說(shuō)明牙周治療更易達(dá)到軟組織的恢復(fù)，而對(duì)于骨組織的再生并未取得令人滿意的效果。加之本研究所納入樣本較少，因此本試驗(yàn)的結(jié)果尚需更大樣本、更長(zhǎng)時(shí)間觀察期和計(jì)劃更加詳盡的研究來(lái)驗(yàn)證。另外，牙周炎是由多種口腔細(xì)菌引起的牙周組織破壞[19-22]，因此筆者建議后續(xù)研究可以將牙周微生物的變化考慮在內(nèi)。

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(2016-11-08收稿 2017-03-20修回)

(責(zé)任編輯 梁秋野)

Comparative study of effect of periodontal flap surgery and caling and root planning before periodontal flap surgery on severe periodontitis

GUO Zhongjun1, LI Ruichun1,HAN Fengqin1,and CHEN Fang2.

1.Department of Stomatology, Weinan Central Hospital，Weinan 714000, China;2.Department of Periodontology & Oral Medicine,School of Stomatology, the Fourth Military Medical University, Xi’an 710032, China

Objective To compare the curative effects of periodontal flap surgery alone and periodontal flap surgery combined with periodontal non-surgery treatment for patients with chronic severe periodontitis.Methods Twenty-eight patients participated in this clinical trial and they were randomly allocated into the control group and the test group. The control group was treated with Modified Widman Flap surgery directly while the test group

scaling and root planning before the same surgery. Bleeding on probing (BOP), pocket probing depth (PPD), clinical attachment loss (CAL) and level of bone (LOB) were examined and recorded at baseline and 3, 6 months later. We used t-test and chi-square test to evaluate the difference between the two groups.Results Both therapeutic methods were conducive to patients, for the measurement indicators improved significantly compared with baseline. 6 months after enrollment, the change of PPD [(4.0±0.23) mmvs(4.9±0.13) mm,P<0.01] reduction and CAL[(5.6±0.30) mmvs(5.5±0.29) mm,P<0.01] gain that had occurred in the test group was more obvious than that of the control group, although there was no significant difference between the two groups at baseline.Conclusions Implementation of scaling and root planning before surgery may bring about better results than surgery alone.

severe periodontitis;periodontal flap surgery;clinical attachment loss

郭忠軍，碩士，主治醫(yī)師。

1.714000，渭南市中心醫(yī)院口腔科；2.710032 西安，第四軍醫(yī)大學(xué)口腔醫(yī)學(xué)院牙周黏膜科

陳 芳，E-mail：42640291@qq.com

R781.4