Documente Academic
Documente Profesional
Documente Cultură
POPA IAI
FACULTATEA DE MEDICIN DENTAR
TEZ DE DOCTORAT
Coordonator tiinific
Doctorand
IAI 2010
Cuprins
INTRODUCERE- MOTIVAIA ALEGERII TEMEI DE CERCETARE ....................4
STADIUL CUNOATERII
CAPITOLUL I
FACTORII ETIOLOGICI AI AFECIUNILOR PARODONTALE.............................4
CAPITOLUL II
FORME DE BOAL PARODONTAL .....................................................................5
CAPITOLUL III
EXAMENUL RADIOLOGIC N BOALA PARODONTAL .....................................6
CAPITOLUL IV
DIAGNOSTICUL N BOALA PARODONTAL.......................................................8
CAPITOLUL V
PRINCIPII DE TERAPIE PARODONTAL ..............................................................9
CERCETARE PERSONAL ........................................................................................... 12
CAPITOLUL VI
OBIECTIVE I METODOLOGIA CERCETRII; CREAREA BAZEI DE DATE I
METODE STATISTICE DE EVALUARE ................................................................12
CAPITOL VII
STUDIU ORTOPANTOMOGRAFIC PRIVIND AFECTAREA PARODONIULUI
PROFUND LA PACIENI CU PARODONTITE CRONICE ....................................15
SCOPUL STUDIULUI ................................................................................................ 15
MATERIAL I METODA ........................................................................................... 15
REZULTATE .............................................................................................................. 17
CAPITOL VIII
STUDIUL PRIVIND EVALUAREA PE ORTOPANTOMOGRAFIE A PIERDERII DE
OS LA UN LOT DE PACIENI CU SUPURAII MANDIBULARE DE CAUZA
ODONTO-PARODONTAL ....................................................................................25
SCOPUL STUDIULUI ................................................................................................ 25
MATERIAL I METODA ........................................................................................... 25
REZULTATE. DISCUII ............................................................................................ 26
2
CAPITOLUL IX
STUDIU
COMPARATIV:
IMAGISTICA
CLASIC
VERSUS
COMPUTER-
PRIVIND
UTILIZAREA
INVESTIGAIILOR
RADIOLOGICE
PARTE GENERAL
STADIUL CUNOATERII
Capitolul I
FACTORII ETIOLOGICI AI AFECIUNILOR
PARODONTALE
Factorii etiologici ai afeciunilor parodontale se clasific n funcie de
originea lor specific, dup cum urmeaz:
FACTORI ETIOLOGICI LOCALI (EXTRINSECI)
o
Determinani placa bacterian
o
Predispozani (favorizani)
De iritaie
coloraii dentare
cariile
igrile i tutunul
tipul de alimentaie
igiena oral
malocluzii
parafuncii ocluzale
pulsiunea limbii
respiraia oral
Capitolul II
FORME DE BOAL PARODONTAL
Dat fiind multitudinea manifestrilor de boal, n decursul timpului s-au
fcut multe tentative de a le clasifica, n funcie de diferite criterii.
Taxonomia bolilor parodontale difer puin de la un autor la altul n unele
incluzndu-se i gingivitele, n altele fiind cuprinse numai bolile parodontale.
Dintre numeroasele clasificri ale bolilor parodontale, citm: cea a lui
Lindhe, stabilit n funcie de gradul de afectare al parodoniului, cea a lui
Genco (1969), Slots (1979), Page i Schreder (1982), Suzuki (1988), Carranza
i Newman (1996), Dumitriu (1998), Armitage i Christie, 2000.
TIPURI DE BOLI GINGIVALE INDUSE DE PLAC
Gingivita, forma cea mai comun de boal gingival, este o afeciune
inflamatorie cronic a gingiilor i reprezint o stare reversibil, n cazul n care
se stabilete igiena oral. Fenomenele inflamatorii pot fi asociate sau nu cu
fenomene degenerative, necrotice sau proliferative. Ele constituie prima etap
spre distrucia parodoniului.
Inflamaia nsoete, aproape constant toate formele de boal gingival,
deoarece placa bacterian care produce inflamaia i factorii de iritaie care
favorizeaz acumularea de plac sunt frecvente n mediu gingival.
5
Capitolul III
EXAMENUL RADIOLOGIC N BOALA PARODONTAL
Examenul radiologic este principalul examen complementar utilizat n
parodontologie.
Examenul radiografic este indispensabil, nu numai pentru precizarea
diagnosticului i stabilirea planului de tratament, dar i ca imagine de referin
pentru urmrirea evoluiei cazurilor n timp.
Capitolul IV
DIAGNOSTICUL N BOALA PARODONTAL
Diagnosticul n boala parodontal cuprinde
interconectate, n care trebuie s se determine:
1.
2.
3.
4.
patru
etape
strns
Tipul maladiei
Bacteriile patogene- tiparele microbiene
Starea de activitate sau inactivitate a bolii
Importana pierderii de ataament
8
1. Tipul de boal
Se definete dup nregistrarea istoricului medical general, a istoricului
special (local) dentar i a tuturor datelor obinute individual la nivelul dinilor i
parodoniului, prin examene clinice i paraclinice.
2.Natura florei bacteriene
Natura florei bacteriene, poate fi evaluat n cabinetul stomatologic prin
mijloace simple, precum microscopia optic cu contrast de faz, metoda avnd
avantajul de a fi simpl, rapid, obiectiv i de a nu seleciona specii rezistente,
astfel se identific compoziia plcii subgingivale pe criterii strict morfologice
(sunt comercializate sisteme complet automatizate Affirm DP).
3 Starea de activitate sau inactivitate a bolii
Se evalueaz pe baza urmtoarelor criterii:
microbiologice,
clinice,
biologice.
4.Stadiul de evoluie al bolii parodontale-pierderea
ataament
Se poate evalua n mod curent prin:
1. Examen vizual,
2. Msurarea adncimii pungilor/nivelului de ataament,
3. Msurri radiografice.
de
Capitolul
Capitolul V
PRINCIPII DE TERAPIE PARODONTAL
SCOPURILE TERAPIEI PARODONTALE
Un tratament parodontal bine realizat trebuie:
s elimine durerea,
s elimine inflamaia i sngerarea gingival,
s reduc pungile parodontalesi s elimine infecia,
s opreasc distrucia esuturilor moi i a osului,
s reduc mobilitatea dentar anormal,
s stabileasc o funcie ocluzal optim,
n anumite cazuri s restaureze esuturile distruse de boal,
s restaureze conturul gingival fiziologic necesar prezervrii
sntii parodontale,
s previn recidiva bolii i s reduc pierderea dinilor.
9
- pungilor, inflamaiei, ,
- ocluziei i mobilitaii dentare,
- alte modificri patologice.
Evaluarea rezultatelor n timp se bazeaz, desigur, pe examenul clinic
i n special pe cel radiologic, singurul care ne ofer informaii obiective despre
evoluia resorbiei osoase. Retracia gingival asociat cu resorbie osoas
marginal i interradicular precum i periodicitatea simptomatologiei sau chiar
pierderea dinilor indic, n mod evident, un eec al tratamentului.
TERAPIA CHIRURGICAL N AFECIUNILE PARODONTALE
Alegerea unei metode chirurgicale se bazeaz pe o serie de consideraii
precum:
Caracteristicile pungii (adncime, configuraie, relaie cu osul);
Accesibilitatea pentru instrumentare;
Existena problemelor muco-gingivale;
Rspunsul la faza etiologic a terapiei;
Cooperarea pacientului (meninerea igienei orale corecte);
Vrsta i starea general a pacientului;
Diagnosticul global de boal;
Consideraii estetice;
Tratamente parodontale anterioare.
Manoperele de chirurgie parodontal se pot mpri n:
1. manopere destinate tratamentului pungilor parodontale:
chiuretajul parodontal,
ENAP, ENAP-modificat,
gingivectomia,
intervenii cu lambou (Widman modificat).
2. chirurgia osoas destinat tratamentului leziunilor osoase:
prin substracie osteoplastia,
prin adiie comblare,
prin regenerare ghidat,
tehnici combinate RTG+comblare,
3. chirurgie muco-gingival destinat corijrii problemelor legate de
rapoartele anormale ntre gingia ataat i mucoasa alveolar.
11
Cercetare personal
14
Capitol VII
STUDIU ORTOPANTOMOGRAFIC PRIVIND AFECTAREA
PARODONIULUI PROFUND LA PACIENI CU
PARODONTITE CRONICE
SCOPUL STUDIULUI
Ne-am propus studiul afectriii parodoniului profund, a relaiei acestei
afectrii cu factori favorizanti locali (obturaii incorecte, coroane de nveli
incorect adaptate), cu prezenta obturaiilor radiculare i a leziunilor periapicale,
precum i comparaia afectrii pe dini omologi, pe fiecare tip de dinte (incisivi,
canini, premolari i molari).
MATERIAL I METODA
Studiul s-a realizat pe un lot de 112 de pacieni, cu vrsta cuprins ntre
25-69.ani, 71 femei i 41brbai alei aleatoriu din pacienii care s-au prezentat
pe parcursul a 3 ani pentru diferite afeciuni dentare la un cabinet de medicina
dentar. Au fost exclui pacienii cu afeciuni sau medicaie care ar putea
influena metabolismul osos.
Criteriul de participare a fost vrsta de minim 25 de ani:
boal parodontal sever sau moderat netratat
parodontit recurent fr chirurgie parodontal
cel puin pentru ultimele 24 luni,
igien oral indiviual eficient (plac <35%)
Examinarea clinic
Dup finalizarea tratamentului parodontal iniial ce cuprindea instruciuni
privind igiena oral i detartrajul supragingival, s-a msurat adncimea pungii
(AP) n patru situsuri ale fiecrui dinte.
Cu o sptmn nainte de terapia de test s-a evaluat indicele gingival (GI)
i indicele de plac n ase situsuri (mezio-vestibular, medio-vestibular, distovestibular, disto-lingual, medio-lingual, mezio-lingual) a fiecrui incisiv, canin
sau premolar.
AP i nivelul de ataament au fost msurate pn la 0,5mm folosind sonda
parodontal n ase situsuri per dinte.
Sngerarea la sondare a fost nregistrat la aproximativ 30 de secunde
dup sondare.
Toate msurtorile clinice au fost realizate de ctre o singur persoan
care a efectuat, de asemenea, i terapia parodontal activ (debridare
subgingival i chirurgie) la toi pacienii.
15
16
REZULTATE
n studiu au fost evaluati numai dinii mandibulari ai pacienilor deoarece
la nivelul molarilor maxilari nu s-a putut determina nivelul osos pentru toate
cele trei rdcini, iar la nivelul premolarilor datorit suprapuneii imaginilor
radiografice.
250
200
150
y = 0.6574x + 36.31
R2 = 0.4152, P<0.0001
100
50
0
0
50
100
150
200
250
Fig 7.1. Evaluarea corelaiei ntre resorbia osului alveolar de pe feele meziale
ale dinilor omologi
Coeficientul de regresie (b) este n acest caz 0,6574. Aceasta este de fapt
valoarea cu care crete y atunci cnd x crete cu o unitate. R2 = 0.4152 arat ce
proporie din variaia variabilei dependente sau prezise (y) este explicat de
model (ecuaia de regresie). n cazul nostru, variana criteriului (y) este comun
sau explicat de predictorul x n proporie de 65%.
300
250
200
150
y = 0.6067x + 42.416
2
R = 0.3189, P<0.0001
100
50
0
0
50
100
150
200
250
Fig 7.2. Evaluarea corelaiei ntre resorbia osului alveolar de pe feele distale ale
dinilor omologi
17
0.9
0.8
0.7
0.6
0.5
0.4
0.3
y = 0.4066x + 0.2418
2
R = 0.1398, P=0.001
0.2
0.1
0
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Fig 7.3. Evaluarea corelaiei ntre resorbia osului alveolar raportat la lungimea
rdcinii de pe feele meziale ale dinilor omologi
0.5
0.4
0.3
y = 0.2395x + 0.2126
2
R = 0.1044, P<0.0001
0.2
0.1
0
0
0.1
0.2
0.3
0.4
0.5
0.6
Fig 7.4. Evaluarea corelaiei ntre resorbia osului alveolar raportat la lungimea
rdcinii de pe feele distale ale dinilor omologi
18
1.2
0.8
0.6
0.4
y = 0.3847x + 0.2702
R2 = 0.1135, P<0.0001
0.2
0
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Fig 7.5. Evaluarea corelaiei ntre resorbia osului alveolar raportat la lungimea
dintelui de pe feele meziale ale dinilor omologi
Coeficientul de regresie (b) este n acest caz 0,3847. n acest caz, variana
criteriului (y) este comun sau explicat de predictorul x n proporie de 11%.
0.9
0.8
0.7
0.6
0.5
0.4
y = 0.4079x + 0.1814
2
R = 0.1258, P<0.0001
0.3
0.2
0.1
0
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Fig 7.6. Evaluarea corelaiei ntre resorbia osului alveolar raportat la lungimea
dintelui de pe feele distale ale dinilor omologi
19
250
200
150
y = 0.7001x + 32.541
R2 = 0.4783, P<0.0001
100
50
0
0
50
100
150
200
250
Fig 7.7. Evaluarea corelaiei ntre resorbia osului alveolar de la nivelul dinilor
omologi
Coeficientul de regresie (b) este n acest caz 0,7001 Aceasta este de fapt
valoarea cu care crete y atunci cnd x crete cu o unitate. R2 = 0.4783 arat ce
proporie din variaia variabilei dependente sau prezise (y) este explicat de
model (ecuaia de regresie). n cazul nostru, variana criteriului (y) este comun
sau explicat de predictorul x n proporie de 47%.
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
y = 0.452x + 0.2337
R2 = 0.1709, P<0.0001
0.1
0
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Fig 7.8. Evaluarea corelaiei ntre resorbia osului alveolar raportat la lungimea
rdcinii de la nivelul dinilor omologi
Coeficientul de regresie (b) este n acest caz 0,452. Aceasta este de fapt
valoarea cu care crete y atunci cnd x crete cu o unitate. R2 = 0.1709 arat ce
proporie din variaia variabilei dependente sau prezise (y) este explicat de
model (ecuaia de regresie). n cazul nostru, variana criteriului (y) este comun
sau explicat de predictorul x n proporie de 17%.
20
0.6
0.5
0.4
0.3
0.2
y = 0.4127x + 0.1734
R2 = 0.1564, P<0.0001
0.1
0
0
0.1
0.2
0.3
0.4
0.5
0.6
Fig 7.9. Evaluarea corelaiei ntre resorbia osului alveolar raportat la lungimea
dintelui de la nivelul dinilor omologi
Coeficientul de regresie (b) este n acest caz 0,4127. Aceasta este de fapt
valoarea cu care crete y atunci cnd x crete cu o unitate. R2 = 0.1564 arat ce
proporie din variaia variabilei dependente sau prezise (y) este explicat de
model (ecuaia de regresie). n cazul nostru, variana criteriului (y) este comun
sau explicat de predictorul x n proporie de 15%.
Deasemenea, s-au observat corelaii semnificative ntre resorbia osului
alveolar, ntre resorbia osului alveolar raportat la lungimea rdcinii i ntre
resorbia osului alveolar raportat la lungimea dintelui de la nivelul dinilor
omologi (figura 7.7, 7.8 i 7.9). , premolarilor si molarilor (P<0.05)
160
*
140
*
*
*
120
100
80
60
40
20
0
Incisivi
Canini
Premolari
Molari
0.7
***
***
***
0.6
0.5
0.4
0.3
0.2
0.1
0
Incisivi
Canini
Premolari
Molari
***
***
***
0.5
0.4
0.3
0.2
0.1
0
Incisivi
Canini
Premolari
Molari
140
120
100
80
60
40
20
0
Stanga
Dreapta
0.5
0.4
0.3
0.2
0.1
0
Stanga
Dreapta
vedere statistic ntre stnga i dreapta, p > 0.05 n ceea ce privete resorbia
osului alveolar raportat la lungimea rdcinii.
0.45
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
Stanga
Dreapta
Capitol VIII
STUDIUL PRIVIND EVALUAREA PE
ORTOPANTOMOGRAFIE A PIERDERII DE OS LA UN LOT
DE PACIENI CU SUPURAII MANDIBULARE DE CAUZA
ODONTO-PARODONTAL
SCOPUL STUDIULUI
Scopul acestui studiu este de a evalua afectarea parodontal i starea de
sntate oral a pacienilor cu supuraii mandibulare de cauza odontogen.
MATERIAL I METODA
Am folosit un tip de studiu transversal caz-control. Studiul s-a facut pe un
lot de 59 de pacieni cu supuraii mandibulare, care au necesitat internare n
Clinica de Chirurgie Maxilo-faciala a Universitatii de Medicina i Farmacie "Gr.
T. Popa", Iasi n perioada noiembrie 2008-octombrie 2009, alei aleatoriu. Lotul
martor a cuprins 54 pacieni fara probleme generale de sntate, alei cu vrsta
comparabil cu cei din lotul de studiu care s-au prezentat n aceeai perioad,
pentru diferite probleme dentare, la un cabinet dentar cu practic privat.
Pentru studiu au fost strnse date privind:
1) condiii socio-demografice (vrst, sex, nivelul veniturilor, nivelul
educaional, fumatul i consumul de alcool),
2) tip de supuraie mandibular i dintele cauzal,
3) starea de sntate oral (numrul de dini, numrul de dini afectai
tratai/netratai, numrul de dini cu tratament endodontic, numrul de dini cu
coroane de inveli).
Gravitatea afectrii parodontale a fost evaluat prin msurarea pe
ortopantomografie a pierderilor de os alveolar. Alveoliza a fost msurat pe
feele meziale i distale ale dinilor Ramfjord folosind un program interactiv.
Programul permite msurarea distanei de la jonciunea smal-cement pn
la nivelul osului alveolar dup o linie paralel cu axul lung al dintelui. O gril
milimetric a fost folosit pentru a transforma numrul de pixeli n milimetri.
Afectarea furcaiilor a fost deasemenea nregistrat. S-a msurat i grosimea
corticalei n dreptul gurii mentoniere, bilateral i valoarea mediei s-a folosit n
studiu. Pentru a obine rezultate comparabile am utilizat un lot de control de 63
de pacieni, cu aceleai caracteristici socio-demografice
Analiza statistic i studiul descriptiv a fost efectuat cu programul de
statistic SPSS (SPSS, Inc., Chicago, SUA). Descrierea populaiei studiate s-a
realizat folosind valorile medii, deviaiile standard i proporiile variabilelor
relevante. Diferenele dintre grupurile de studiu au fost analizate cu ajutorul
testului t pentru eantioane independente. Diferena este statistic semnificativ la
nivelul de semnificaie de 5%.
25
REZULTATE. DISCUII
Majoritatea pacienilor au fost brbai (67,9%), cu mai puin de 12 clase
(71,4%), cu venituri mai mici de 800 RON pe lun (89,3%), fumtori (82,1%) i
consumatori ocazionali de alcool (89,3%).
Din cele 59 de cazuri avute n studiu (fig 8.1):
5 supuraii au fost de cauza parodontal (8,47%),
4 supuraii au fost cauzate de sindromul endo-parodontal
(6,78%),
31 supuraii de cauze endodontice (52,54%),
19 fiind de alte cauze, n principal chirurgicale(32%).
8%
32%
Supuratii
de cauza
parodontal
a
Sindrom
endoparodontal
7%
Supuratii
de cauze
endodontic
e
Alte cauze
53%
De remarcat este proportia mare de supuraii de cauza parodontal i endoparodontal ce au necesitat internare n lipsa unor afeciuni generale, ceea ce se
explic prin virulena biofilmului bacterian implicat.
Evaluarea pierderii de os alveolar a fost apreciat pe OPT, n corelaie cu
examenul clinic. n urma determinrilor fcute am constatat urmtoarele
Pierderea medie de os alveolar a fost semnificativ mai mare n cazul
pacienilor cu supuraii comparativ cu grupul de control. (4,80mm fa de 2,19
mm; P < 0,0001).(fig.8.2)
6
P<0.0001
4.805
2
2.191
1
0
1
Grupul de studiu
2
Lotul martor
26
2.5
P=0.0006
1.821
1.5
0.5
0.3913
0
1
Lot de studiu
Lot de control
Fig 8.3. Numrul de dini cu leziuni interradiculare la cele dou loturi de studiu
5
5.579
4
4.5
0
1
Lot de studiu
2
Lot de control
Cauza dentar cea mai frecvent a supuraiilor dentare a fost primul molar
mandibular (37%), urmat de molarul secund (29,6%) i de molarul de minte
(29,6%). 25,8% dintre pacieni au prezentat supuraia regiunii geniene, 18,5% au
fost diagnosticati cu supuraia regiunii submandibulare, i 18,5% cu supuraia
lojei maseterine.
S-a constat c pacienii cu supuraii mandibulare de cauz dentar prezint
un numr semnificativ statistic mai mare de dini afectai netratai (fig. 8.5), mai
puine obturaii coronare (fig. 8.6), mai puine tratamente endodontice (fig. 8.7)
i mai puine coroane de nveli dect lotul martor (fig. 8.8).
27
7
P<0.0001
5.286
1
1.348
0
1
Lot de studiu
Lot de control
Fig 8.5. Numrul de dini cu leziuni carioase la cele dou loturi de studiu
6
P<0.0001
4.522
0.3214
0
1
Lot de studiu
Lot de control
Fig 8.6. Numrul de dini cu obturaii coronare la cele dou loturi de studiu
3.5
P<0.0001
3
2.5
2.739
1.5
0.5
0.4286
0
1
Lot de studiu
2
Lot de control
Fig 8.7. Numrul de dini cu tratamente endodontice la cele dou loturi de studiu
28
4
P=0.0038
3.5
2.5
2.826
1.5
1.071
0.5
0
1
Lot de studiu
2
Lot de control
Fig 8.8 Numrul de dini cu lucrri protetice fixe la cele dou loturi de studiu
Capitolul
Capitolul IX
STUDIU COMPARATIV: IMAGISTICA CLASIC VERSUS
COMPUTER-TOMOGRAFIE CLASIC (CT)
INTRODUCERE. MOTIVAIA TEMEI DE CERCETARE
Examenele paraclinice, radiologice utilizate n diagnosticul parodontal i n
evaluarea eficacitii tratamentului ales sunt: ortopantomografia, radiografiile
retro-dento-alveolare i mai puin utilizat curent, computer-tomografia.
SCOPUL LUCRRII
Demersul nostru de cercetare a plecat de la realitatea c, de multe ori,
examenele radiografice de rutina (ortopantomografia, radiografiile retro-dentoalveolare i bite-wing) nu ofer suficiente date cu privire la arhitectura
pierderilor osoase verticale, a numrului de perei ososi verticali, a asocierii
acestora cu leziuni infraosoase serpiginoase n cazul molarilor, n special cei
superiori; la acetia, morfologia radicular complex pune de multe ori
probleme de diagnostic corect, ct i probleme n stabilirea celei mai bune
29
30
Fig 9.1. Pacient E.V., 39 ani, parodontit agresiv. Sondaj parodontal 15(a), 16(b)
SCOPUL STUDIULUI
Scopul acestui studiu a fost de a evalua utilitatea tomografiei computerizate
dentare ca explorare diagnostic a afectrii parodoniului profund i msura n
care densitatea osului mandibular se coreleaz sau nu cu numrul dinilor
pierdui i indicele mandibular panoramic superior i inferior.
MATERIAL I METOD.
Am luat n studiu un lot de 69 de computer-tomografii realizate la pacieni
cu diferite grade de efectare a parodoniului profund, n scopul realizrii
reabilitrii parodontale complexe, a aplicrii de implante intraosoase sau de
investigare a poziiei intraosoase a dinilor inclui, naintea instituirii
tratamentului ortodontic. Dei examinare CT nu s-a realizat expres pentru
evaluare parodontal, toi pacienii luai n studiu, prezentau un anume grad de
afectare parodontal.
Computer-tomografiile s-au realizat pe un aparat Somatom Emotion
(Siemens), la Centrul Explora-RX din Iai, Romnia.
Programul Syngo (softul eFilm, al Merge eMed) a fost utilizat pentru
msurarea densitii osoase punctual i pe o anumit suprafa aleas, ct i a
distanelor, n mm.
Din studiu au fost exclui pacienii cu boli generale, cu leziuni patologice la
nivelul oaselor maxilare i cei care luau medicaie care influeneaz
metabolismul osos.
Deoarece determinrile densitii osului interdentar s-au fcut numai pe
dini omologi, din studiu au fost exclui acei dini crora le lipseau, pe imaginile
CT, omologii. Au fost exclui, de asemenea, dinii la care nu s-au putut realiza
msurtorile datorit artefactelor date de restaurrile metalice i brackets-uri.
Lotul de studiu a fost alctuit din 35 de femei i 34 brbai cu vrsta
cuprins ntre 17 i 73 ani.
Studiul a fost orientat pe dou direcii:
36
Fig 10.2 Reconstrucii 2D, sextanii 4-5, msurarea grosimii bazilarei n dreptul
gurii mentoniere
REZULTATE.
16%
7%
<20 a ni
17%
21-30 a ni
31-40 a ni
41-50 a ni
34%
>51ani
26%
49%
Fem ei
Ba rbati
51%
0mm
261.6
340.1
238.0
197.7
269.7
0.5mm
404.6
625.8
509.2
392.9
462.4
1mm
529.2
855.8
587.2
548.6
553.7
1,5mm
517.2
889.7
590.5
608.3
651.8
2mm
478.6
877.5
562.8
593.9
676.8
2.5mm
418.6
792.7
508.9
579.4
650.2
3mm
349.2
661.1
482.2
543.4
653.2
3.5mm
336.7
600.3
457.1
483.9
542.0
4mm
287.4
573.3
413.0
456.0
595.7
4.5mm
264.5
537.8
337.5
476.3
578.7
5mm
266.1
529.7
348.6
392.6
578.1
5.5mm
268.3
511.1
374.2
379.9
554.0
40
Fig 10.6. Media densitii osului alveolar interdentar, pe grupe de vrst, la diferite
adncimi, de la vrful septului pn la 7mm
Comparatii intre media densitatii osului interdentar la dinti cu si
fara tratament ortodontic fix
700
600
500
400
300
200
100
0
Media densitatii osului
alveolar la varful septului
interdentar
41
42
Chiar dac la vrful septului valorile medii ale densitii osoase sunt
apropiate(265.1800HU, respectiv 270.3333HU), la dinii cu i fr tratament
endodontic, la profunzimea de 0,5-35 la dinii cu tratament endodontic am
nregistrat o densitate medie de 572.0333HU, mai mic dect la cei fr
tratament endodontic(587.4640HU). Raportul densitilor se schimb la reperul
3-5,5mm, situaie n care, la dinii cu tratament endodontic, media densitii
osoase (515.1944)este mai mare dect la cei fr tratament (448.2447HU).
700
600
500
me die fara tra ta me nt
400
300
200
100
0
Media densitatii
osului alveolar la
varful septului
interdentar
Media densitatii
Media densitatii
osului alveolar intre osului alveolar intre
0,5-3,5mm
3-5,5mm
profunzime a
profunzime a
septului interdentar septului alveolar
800
Dini
indem ni
700
600
Dini cu
procese
carioase
500
400
300
Dini cu
tratament
endodontic
200
100
0
Media densitatii osului Media densitatii osului Media densitatii osului
alveolar la varful
alveolar intre 0,5alveolar intre 3-5,5mm
septului interdentar
3,5mm profunzime a
profunzime a septului
septului interdentar
alveolar
Dini cu
leziuni
periapicale
Sex
Vrsta (ani)
Tratament
ortodontic fix
Coroane de
nveli
Procese
carioase
Tratament
endodontic
Leziuni
periapicale
R2
F
P
Media
pierderii de
os (mm)
0.356
-0.107
0.184
0.065
-0.002
-0.132
0.112
0.148
0.122
0.477**
0.024
-0.073
-0.138
-0.119
0.203*
0.388**
0.027
0.145
0.263
0.190
0.036
-0.012
-0.058
0.028
0.116
0.072
0.271
0.005
0.092
0.691
NS
0.61
0.445
NS
0.277
2.467
0.031
0.632
11.021
<0.0001
Fig 10.14 Variaia mediei densitii osului alveolar ntre 11-12, respectiv 41-42
45
Shapiro-Wilk
Statistic
df
Sig.
Statistic
d11_12
.213
10
.200*
.933
d42_41
.254
10
.067
.843
a. Lilliefors Significance Correction
*. This is a lower bound of the true significance.
df
10
10
Sig.(p)
.477
.048
46
Fig 10.15 Diagrama scatter a corelaiei densitii osului alveolar ntre 11-12,
respectiv 41-42
s13_12 s22_23
Negative Ranks
Positive Ranks
Ties
Ties
8
6d
4e
0f
Total
10
Total
s12_11 s21_22
N
6a
2b
0c
Negative Ranks
Positive Ranks
Mean
Rank
4.50
4.50
Sum of
Ranks
27.00
9.00
7.50
2.50
45.00
10.00
a. s13_12 < s22_23, b. s13_12 > s22_23,c. s13_12 = s22_23,d. s12_11 <
s21_22,e. s12_11 > s21_22,f. s12_11 = s21_22
47
s13_12 s22_23
Z
-1.260 a
p. (2-tailed)
.208
a. Based on positive ranks.
b. Wilcoxon Signed Ranks Test
s12_11 s21_22
-1.784a
.074
600
21 - 22
400
200
pt
se
vf
de
8m
la
ns
la
pt
pt
se
m
de
de
m
7,
5m
de
la
ns
de
ns
vf
vf
se
vf
de
m
7m
la
se
pt
pt
pt
se
vf
de
vf
de
m
6m
la
6,
5m
de
la
ns
ns
de
de
m
5,
5m
de
5m
la
s
ns
de
se
se
vf
vf
de
m
4,
5m
la
m
de
pt
pt
pt
se
se
vf
de
de
m
4m
la
ns
ns
de
la
pt
pt
vf
vf
de
m
3,
5m
de
la
ns
ns
de
se
se
pt
pt
3m
la
2,
5
2m
de
de
vf
vf
se
se
pt
pt
vf
de
de
la
ns
ns
de
de
ns
de
la
1,
5m
m
1m
la
ns
se
se
vf
de
vf
de
de
va
la
la
ns
ns
de
de
0,
5m
rf u
ls
ep
se
tu
pt
lu
i
Fig. 10.16. pacient P.A. Comparaia densitii septurilor interdentare 12-11 i 2122 (liza osoas orizontal 1 mm)
48
3,69
0,66
3,5000
0,79
NS
0,53
2,96
0,77
<0.05
0,26
0,05
0,22
0,05
NS
0,31
0,08
0,28
0,06
NS
17,06
8,85
20,00
7,47
NS
49
Capitolul XI
XI
STUDIU PRIVIND UTILIZAREA INVESTIGAIILOR
RADIOLOGICE N STABILIREA OPIUNII TERAPEUTICE TRATAMENT CONSERVATOR SAU CHIRURGICAL I
EVALUAREA RSPUNSULUI LA TRATAMENT
SCOPUL STUDIULUI
Scopul studiului a fost de a aprecia utilitatea examenului radiografic, n
conjuncie cu examenul clinic n stabilirea opiunii terapeutice -tratament
conservator sau chirurgical la pacieni cu diferite forme de boal parodontal i
evaluarea rspunsului la tratament.
MATERIAL I METOD
Grupul de studiu a fost format din 82 de pacieni diagnosticai cu boal
parodontal moderat sau sever.
Criteriile de participare au fost:
o vrsta de minim 20 de ani,
o boal parodontal n diferite stadii, netratat
o parodontit recurent fr chirurgie parodontal cel puin pentru
ultimele 24 luni,
o igien oral indiviual eficient (plac <35%)
o consimmnt dat n scris.
n funcie de forma clinic de boal evaluat att clinic (anamnez, ex
intra/extraoral, evaluarea factorilor locali de retenie, sondaj parodontal) ct i
paraclinic (OPT, radiografii periapicale, CT) s-au constituit dou loturi de
pacieni:
o Lot de pacieni la care s-a realizat numai tratament parodontal
consevator detartraj supra/ subgingival, surfasaj +/- tratament
antimicrobian.
o Lot de pacieni la care s-a realizat pe lng terapia iniial i
abordul chirurgical al leziunilor parodontale.
EXAMINAREA CLINIC
S-au nregistrat, n conjuncie cu factorii locali (ce in de situs) i factorii
ce in de pacient, urmtorii indici parodontali:
o indicele de plac (IP),
o indicele gingival (IG),
o adncimea pungii (AP),
o nivelul pierderii ataamentului clinic (PA),
50
Prognostic bun
Prognostic bun
Prognostic rezervat
X
X
X
X
X
X
Nerecuperabil
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
REZULTATE -DISCUII
Caracteristicile loturilor luate n studiu sunt redate n continuare
29%
P agresiv
P cronic
71%
23%
33%
Iniia l
M ode ra t
S eve r
44%
74,9%
61,4%
54,9%
72,7%
62,5%
17,3%
23,8%
26,3%
20%
23,2%
14,4%
18,5%
7,3%
13,8%
54
Din aceste date constatm c exist o relaie direct ntre gradul pierderii
de ataament i prezena tartrului dentar.
Putem aprecia c aceste procente sunt dependente n mare msur de
nivelul de educaie sanitar i de igien oral al pacienilor, indiferent de starea
lor sistemic.
Au fost msurate recesiuni gingivale vizibile mai mari sau egale cu 2 mm.
Suprafeele cu recesiuni gingivale au fost semnificativ mai mari la lotul cu
tratament chirurgical (4,3+/-4,2) fa de lotul fr tratament chirurgical (1.4+/2,5).
Aproximativ 66% din pacienii din lotul fr tratament chirurgical i 32%
din pacienii lotului cu tratament chirurgical nu prezint recesiuni gingivale; 7%
din pacienii cu indicaie de tratament conservator i aproximativ 36% din cu
indicaie de tratament chirurgical au mai mult de 5 suprafee cu recesiuni.
Tabel 11.IV - Prezena i distribuia pacienilor din cele dou loturi n funcie de
numrul de situsuri cu pierdere de ataament
CH (%) C(%)
CH(%)
C(%)
Nr
situsuri
2 mm
3-4mm
0
12,8
24,3
62,5
74,8
1-5s
32,6
60,6
32,6
25,2
6-10s
21,8
12,6
4,9
0,0
11-15s
19,7
2,5
0,0
0,0
16-20s
10,7
0,0
0,0
0,0
>20s
22
0,0
0,0
0,0
CH - tratament chirurgical, C - tratament conservator
CH(%)
>4mm
15,1
32,6
28,4
10,9
10,8
2,2
C(%)
30,0
57,3
10,2
2,5
0,0
0,0
56
Monitorizarea clinic
Parametrii clinici medii (PA-pierderea de ataament, AP adncimea
pungii, IP-indicele de plac, IG indicele gingival) la evaluarea situsurilor sunt
redai n Tabelul 11.V.
Tabel 11.V.Parametrii clinici evaluai iniial, la 3 i respectiv la 6 luni
Examinare
Iniial
La 3 luni
La 6 luni
Situsuri
3246
3228
3228
PA(mm)
5,122,20
4,871,87
4,921,84
AP (mm)
4,921,84
2,671,19
2,671,20
IG
0,780,97
0,510,86
0,510,86
IP
0,9700,51
0,780,970
0,780,970
n tabelul urmtor (Tabelul 11.VI ) sunt redate datele cu privire la tipurile
de terapie realizate (fr terapie, detartraj/surfasaj, abord chirurgical).
Tabel 11.VI. Parametrii clinici nregistrai la loturile de studiu
Fr terapie
Situsuri
PA (mm)
AP(mm)
IG
IP
786
4,351,82*
4,351,82*
2,451,13*
0,150,49
Detartraj/
surfasaj
1640
5,552,30
3,661,98
0,941,00
01,60,53
Chirurgie parodontal
820
5,392,02
392,02
1,020,98
0,140,49
57
Fig 11.11. Pacient P.M. Examenul radiografic arat regenerarea osului alveolar n cazul
lizelor verticale de la nivelul 14, 15, la un an dup terapia prodontal (chiuretaj parodontal n
cmp deschis)
a
Fig 11.12. Pac A.D., 42ani, RX retro-dento-alveolara iniial (a), dup tratament etiologic (b);
reducerea dimensiunii defectului osos la 1 an dup regenerare tisular ghidat (c)
Fig 11.13. Pacient C.D, valoarea dimensiunii defectului osos nainte de tratamentul
etiologic
58
a. Initial
b. La 6 luni
c. La 12 luni
unghi A1-D1-B1 = = 30
unghi A1-D1-B1 = 21
unghi A1-D1-B1 = 17
Rezultate
corelaii statistic semnificative (p = 0.036) ntre aparena radiografic a
unghiului defectului infraosos i adncimea defectului infraosos (msurat
de la jonciunea amelo-cementar la limita apical a defectului)
la aproximativ 2,3% din subiecii grupului test defectele infraosoase au
fost trecute cu vederea i subestimate de examinarea radiografic apical
probabilitatea unui ctig de ataament clinic de 4mm este de 3,2 mai
mare pentru defectele osoase cu valori angulare mai mici de 20 dect cele
cu valori angulare mai mari de 35, i cu 2,7 mai mari dect cele cu valori
intermediare.
Parametrii radiografici pot fi utilizai pentru realizarea unui
diagnostic parodontal, pentru a crea un plan de tratament, pentru a estima
riscul de boal, pentru a documenta stabilitatea tisular, remodelarea sau
progresia leziunii i poate pentru a detecta factorii de risc parodontali.
Evaluarea radiografic a regenerrii osoase reclam i ea tehnici de
standardizare pentru poziionarea reproductibil a filmului i tubului. Chiar i n
cazul tehnicilor standardizate, radiografia nu va arta ntreaga topografie a zonei
nainte sau dup tratament. Mai mult, nainte de tratament pot exista zone de
esut conjunctiv osos subiri, care rmn nedetectate radiografic datorit faptului
c o anumit cantitate de esut mineralizat trebuie s fie prezent pentru
nregistrarea pe radiografie. Un numr de studii au demonstrat c radiografiile,
sunt fiabile, mai les cele realizate cu metode standardizate.
64
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