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[正畸] #临床指南 正畸引发牙根外吸收的诊疗策略

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发表于 2020-7-28 15:19:32 | 显示全部楼层 |阅读模式
灵魂拷问:今天你博学了么?

如果没有……那么机会来了!



众所周知,牙根外吸收是个让所有正畸医生头疼的话题。

你一定见过这样的……


以及这样的……


如果没有……那……                 

病例做得太少啦!



既然此坑绕不开也逃不掉,我们今天就来学习一下针对 “正畸引发牙根外吸收 (EARR)” 的最新临床指南。





近期,European Journal of Orthodontics 刊登了一篇名为Development of a clinical practice guideline for orthodontically induced external apical root resorption”  的文章,旨在通过循证医学的方法评估现有临床证据,从而总结针对 “正畸引发牙根外吸收” 诊断、危险因素、矫治中矫治后的临床应对策略

本文通过 系统性分析方法 (systematic review)从MEDLINE和Embase查阅收集具体涉及以上四个临床问题 (CQ#1-#4)的相关证据。经过层层筛查,从最初得到的794篇文献,得到最终的8篇,并用GRADE证据质量分级和推荐强度系统(Grading of Recommendati** Assessment, Development, and Evaluation)对其进行评估,结果显示:


由此,作者们开发了一份针对“正畸引发牙根外吸收 (EARR)”的最新临床指南(Authorized by NVvO, Dutch Association of Orthodontics)
CQ#1 诊断
  • 正畸起始后12个月,建议对所有拔牙固定矫治的患者拍摄全景片,并与初始影像资料对照C**ider taking an OPT at 12 months after starting fixed appliances in a patient with any extraction treatment. Compare this OPT to the OPT taken at the start of orthodontic treatment, when available. Weak recommendation

  • 如果从现有影像资料无法充分辨别根尖长度及形态,建议加摄根尖片

    C**ider taking additional periapical radiographs when the available radiographs do not provide adequate information about the shape and size of the roots. Weak recommendation



CQ#2 危险因素
  • 正畸治疗开始前,告知患者有牙根外吸收风险

    Inform the patient prior to orthodontic treatment about the risk of EARR. Strong recommendation

  • 如果治疗方案涉及拔牙,建议告知患者因此可能增加牙根外吸收的风险

    When an extraction treatment is planned, inform the patient of the possibility that it is associated with increased risk of severe EARR. Strong recommendation



CQ#3 治疗策略
  • 正畸过程中如果发现牙根外吸收不小于2 mm,需重新评估诊疗目标和方案。建议告知患者后果,根据患者喜恶,进一步确定治疗目标的优先级Re-evaluate the treatment goals and treatment plan when EARR is detected (≥2 mm) during an orthodontic treatment. Inform the patient and discuss the c**equences, the patient’s preferences, and the treatment goals. Strong recommendation
  • 当观察到广泛的重度牙根外吸收,建议考虑终止正畸治疗
  • C**ider stopping orthodontic treatment when generalized severe EARR occurs. Weak recommendation

  • 建议不进一步给出现重度牙根外吸收的牙齿继续加力C**ider avoiding further loading on teeth that exhibit severe EARR. Weak recommendation
  • 决定是否继续正畸治疗时,建议考虑暂时中止疗程三个月,并确保之前受累牙在此期间被动不受力

    When deciding to continue active orthodontic treatment, c**ider discontinuing treatment for 3 months. Make sure that the appliance is passive during that time to avoid loading the affected teeth. Weak recommendation


  • 决定继续正畸治疗后,建议尽量避免移动受累牙
  • When deciding to continue orthodontic treatment, attempt to avoid displacement of the affected teeth. Strong recommendation

  • 三个月暂停期过后若决定继续行正畸治疗,建议六个月后再次采集影像资料
  • When deciding to continue active orthodontic treatment after a treatment interruption of 3 months, c**ider taking a new radiograph at 6 months after the restart. Weak recommendation


CQ#4 正畸保持
  • 建议遵照常规正畸保持方案

    Follow the patient according to your normal retention protocol. Strong recommendation


  • 建议告知患者受累牙的长期预后(至少涵盖:牙根外吸收会在拆除矫治器后终止;牙根外吸收不会导致疼痛或其他不适;若根长低于10mm, 受累牙可能有松动且可能逐渐增加;若出现牙周疾病,受累牙可能早失)Patient information about the long-term prognosis must include at least the following:
  • EARR will stop after the appliances are removed.
  • EARR will not lead to pain or discomfort (sensibility).
  • The affected tooth may be mobile, and mobility might increase over time (for root lengths less than 10 mm).
  • Affected teeth might be lost earlier, if periodontal bone destruction (periodontitis) occurs. Strong recommendation

  • 建议叮嘱患者在治疗结束后仍然和正畸医生保持良好沟通,及时告知医生受累牙情况 (牙周病筛查;确定保持器对牙齿被动不受力)

    Take care of a good communication with the dentist at the end of treatment to inform the dentist about affected teeth and advice:


  • periodical screening for periodontal diseases, especially around the affected teeth.
  • assurance that retention devices remain passive after the regular retention check-ups with the orthodontist have ended. Strong recommendation



References:
  • The Appraisal of Guidelines for Research and Evaluation II instrument.
  • Chen, Y., et al.; RIGHT (Reporting Items for Practice Guidelines in Healthcare) Working Group (2017) A reporting tool for practice guidelines in health care: the RIGHT statement. Annals of Internal Medicine, 166, 128–132.
  • Dutch Method for Evidence-Based Guideline Development (KNAW, KNMG, GR, NHG, FMS (2016) Code ter Voorkoming van Onei- genlijke Beïnvloeding Door Belangenverstrengeling, 5 September 2018, date last accessed).
  • Caroline F W Sondeijker, Antoon A Lamberts, Stefan H Beckmann, Reinder B Kuitert,Koen van Westing, Saskia Persoon, Anne Marie Kuijpers-Jagtman, Development of a clinical practice guideline for orthodontically induced external apical root resorption, European Journal of Orthodontics, Volume 42, Issue 2, April 2020, Pages 115–124.


今天充电内容到此结束
是不是感觉自己更帅了


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