http://www.dxy.cn/bbs/post/view?bid=103&id=14160148&sty=1&tpg=1&age=0&ticket=ST-505992-H5WVxDXbsJ7cXgD64r2yMH7G2oSEETpbH5V-20

医学是在不断发展的，知识更新是医学工作者必须的，不论是中国医生还是外国同行。就“选择性抛光”来说，写进国外教科书大概也时间不长，工作１０几年的牙医不学习的话也根本上形势。

北美有资格作牙周病防治的可以是牙医、或洁牙师RDH，后者没有处方权，但是工作更专一，“选择性抛光”　可能先出现在RDH教科书里。

以下是DinoDMD医生发在某牙周病论坛的帖子，他的夫人正好是RDH，他从夫人书上学来不少东西。DinoDMD的求学态度非常可敬！

关于抛光，要补充的一点是：不要在洁治当天抛光，因为洁治后牙周袋是敞开的，很容易收抛光剂刺激（这也应当包括喷砂抛光！）；牙敏感也会增加。建议４ｗ后牙周再评估时抛光。

Here a portion of a chapter from my wife's hygiene book regarding stain removal and effects of polishing on teeth...
(Wilkin's Clinical Practice of the Dental Hygienist, 10th edition)

I actually been reading this book alot lately

_______________


Extrinsic Stain Removal
Caren M. Barnes RDH, MS


After treatment by scaling, root planing, and other dental hygiene care, the teeth are assessed for the presence of remaining dental stains. The use of cleaning and polishing agents for stain removal is a selective procedure that not every patient needs, especially on a routine basis.
Preliminary examination of each tooth will reveal that the surfaces to be treated may be tooth structure (enamel, or with recession cementum or dentin) or when restored, a variety of dental materials (metal or tooth-color restorations). Preservation of the surfaces of both the teeth and the restorations is involved.
The longevity, esthetic appearance, and smooth surfaces of dental restorations depend on appropriate care by the dental hygienist and the daily personal care by the patient. It is a responsibility of the dental hygienist to be current in knowledge of the procedures to prevent damage to the restorations during professional healthcare appointments. In addition, the dental hygienist is responsible for educating the patient about proper personal daily care that will contribute to the maintenance of the restorations.
Purpose of Stain Removal
Stains on the teeth are not etiologic factors for any disease or destructive process. Therefore, the removal of stains is for esthetic, not for health, reasons. The term “selective polishing” is used to indicate that polishing procedures are to be included where there is a need just as all dental hygiene care is selected for the patient.

Effect on Teeth

A. Removal of Tooth Structure
Polishing for 30 seconds with a pumice paste may remove as much as 4 µm of the outer enamel.
The outermost layer of tooth structure contains the greatest amounts of fluoride. The surface fluoride protects against dental caries. The concentration of fluoride drops quickly inward toward the dentin, so if the surface layer is polished away, the protection is greatly diminished.
The fluoride-rich surface is necessary for protection against dental caries and care is taken that it be preserved.

B. Areas of Demineralization
Demineralization areas: More surface enamel is lost from abrasive polishing over demineralized white spots than over intact enamel.
Remineralization of a demineralized area can be interrupted when the surface enamel is removed.

C. Areas of Thin Enamel, Cementum, or Dentin
Amelogenesis imperfecta is an example of thin enamel resulting from imperfect tooth development
Exposure of dentinal tubules: cementum and dentin are softer and more porous, so greater amounts of these can be removed during polishing than enamel. When cementum is exposed because of gingival recession, polishing of the exposed surfaces is avoided.
Smear layer can be removed and dentinal tubules exposed.
When surface structure is removed, unnecessary tooth sensitivity can result.

D. Care of Restorations and Implants
Use of coarse abrasives may create deep, irregular scratches in restorative materials that will make them retain stain and plaque more readily.
Microorganisms collect and colonize on a rough surface much more rapidly than on a smooth surface.
It is imperative that tooth polishing agents not be utilized on restorative materials. Polishing pastes not intended for use on restorative materials can destroy the surface integrity of the dental material.The only safe material that will not damage the surface characterization of a restoration is a cleaning agent or a polishing agent that is recommended by the manufacturer of the restorative materials.

E. Heat Production
Steady pressure with a rapidly revolving rubber cup or bristle brush and a minimum of wet abrasive agent can create sufficient heat to cause pain and discomfort for the patient.
Damage to the pulp by the heat has not been documented, but the pulps of children are large and may be more susceptible to heat.
The rule is light pressure, a slow-motion instrument, and plenty of moisture mixed with the abrasive agent.

IV. Effect on Gingiva
Trauma to the gingival tissue can result, especially when the prophylaxis angle is run at a high speed and the rubber cup is applied for an extended period adjacent to gingival tissues.
As reported, a rubber cup with pumice rotated for 2 minutes caused total removal of the epithelium inside the crest of the free gingiva. Complete healing from such a wound takes 8 to 14 days.
The soreness and sensitivity of the tissues could prevent adequate biofilm removal by the patient during that time, and a severe inflammation could result, along with calculus reformation.
With the fast rotation of a rubber cup, particles of a polishing agent can be forced into the subepithelial tissues and create a source of irritation.
Stain removal after gingival and periodontal treatments, including scaling and root planing, is not recommended on the same day. The diseased lining of the pocket usually has been removed, and the pocket wall is wide open and can receive particles that may become embedded out of reach of the most careful irrigation and rinsing.
Foreign-body reactions to abrasives have been tested. Several agents have been shown to have potential for creating reactions. Some explanation for delayed healing following tissue trauma may be found in this concept.
________________________

Hope this helps,
Dino

以下是另一位牙医的建议：

I never polish the teeth on the same day as SRP. Not so much because I'm afraid of the possible side effects that are listed above but because it seems pointless and a waste of time. Add that to the possible negative side effects and there you have it. When the patient comes in for their 4-6 week tissue check I'll do their polish then...also this gives them sort of an "incentive" to make it to that apt. if they are one of those patients who really values the polish.

There is absolutely no therapeutic value to polishing and SRP is a periodontal treatment or therapy. Also, I'm always trying to make the distinction clear to the patients between a prophy, perio maintenance and SRP. I think that performing a polish after SRP will send the patient the wrong message, the "cleaning" message "I just got my teeth cleaned" is what they'll be thinking as they walk out tasting the grit...
菌斑不仅可以附着在牙面上，还可以附着在修复体上。因此，有效的菌斑去除不只是牙周科的事情，也是修复科医生需要考虑的。不幸的是，很多修复科大夫缺乏全科意识，修复体成了人造结石、慢性拔牙器。

一些修复科大夫易犯的，牙周问题欠考虑的错误有：
侵犯生物学宽度；
边缘悬突或不密合；
邻接点差；
牙体外形差，不利于食物排溢和牙龈保健；
ｈｅ创伤问题；
滥用联冠或“牙周夹板”等等。

如下图联冠，不知道修复前牙周病基础治疗了没有？牙龈明显有问题，临间隙菌斑也不少。唉！
http://img.dxy.cn/upload/2009/03/22/22167611.jpg

不使用牙线是中国人的“习惯”，殊不知即使用正确的刷牙方法也很难去除临面菌斑，临间隙增大的可能还需要使用如图的特殊牙线、间隙刷、牙签等。

参考文献－－Wilkin's Clinical Practice of the Dental Hygienist, 10th edition
http://img.dxy.cn/upload/2009/03/22/52766599.jpg 
修复体涉及时，必须考虑到是否利于患者有效的自洁，包括桥基牙的牙周袋、连接体下方、桥体底部。一般说来，要牙线可以通过，必要时借助threader(如图，有的dental floss 一端较硬，也能通过临间隙)
http://img.dxy.cn/upload/2009/03/22/22288019.jpg 
旧的盖脊式、填死牙间隙不利自洁的桥体应当弃用。

我曾经见有的网站有关于“根形桥体”无法自洁的讨论。但是这样的病例司空见惯，果真无法自洁吗？

如下病例是用激光作龈成形术后修复的病例。参见原文：This decision to take the final impression should be made on a case-by-case basis and is determined by several factors, including the patient’s level of expectations, the extent of the surgery, the patient’s ability to maintain adequate plaque control, and the patient’s degree of compliance. Furthermore, in recent extraction sites, it is best to provide a long-term provisional for final stabilization, which can take from 4–12 months. However, in most cases, final restorations can be seated in three to four weeks (Fig. 12). As of this writing, no other method provides this level of predictability. To aid healing and prevent relapse, the altered tissue site should be supported with provisional restorations that mimic the ovate pontic design of the definitive restoration。

http://www.agd.org/publications/articles/?ArtID=4324

显然，这是一例美观效果非常好的典范，而且作者考虑到了自洁，桥体底部是ovate pontic design。如何自洁？
http://img.dxy.cn/upload/2009/03/22/79567000.jpg 

如图所示（牙线从临间隙进入，沿桥体略向冠方拉动）。

看来，“根形”桥体是不能一棍子打死的，是能达到利于自洁的设计的。只是您作根形桥体时要考虑到自洁，并且教给患者正确自洁方式。

实际上，激光、电刀、陶瓷牙龈磨头用于牙周手术还是大有市场的。
http://img.dxy.cn/upload/2009/03/22/80630894.jpg 
这些牙周基础治疗的理论，国内书籍很贫瘠，因为牙周病专业本身就是非常被忽视的学科；而欧美日、甚至香港等都有dental Hygiene专业，理论非常系统，技术要求几乎细致到“吹毛求疵”的地步－－在我刚接触这些书和理论的时候是有这个感觉。因此我也一直犹豫是不是把这些鸡毛蒜皮、不挣钱的玩意发在这里，很多牙医甚至不认识最基本的器械分类，再谈支点、角度好像扯远了－－这不是哪个个别牙医的错，我国口腔现状不是几个丁香园的网友造成的。

还是交流些实际技术问题吧－－记的以前有个战友问　“左上后牙支点如何寻找？”　针对不同器械，我的思路大致如下：

１－超声波洁治＋手工器械是最有效的基础治疗方式。超声波洁治、牙周袋探针，因为极少需要侧向力，故可以选择口内、口外支点。超声波洁治头对人触觉有影响，小的龈下结石必须结合探针、刮治器等。

２－计划洁治一个后牙区，建议从最后一个牙做起；

３－结石较多时，用超声波或洁治器先去除龈上结石（好的超声波洁治器配有龈下工作头、根分叉工作头，普通工作头达不到这些区域）。锄形器以前用于去除大块结石，现实用较少了；接着用刮治器去除龈下结石；

４－GRACEY-13/14用于后牙远中面，对于中国人口腔小、龈下结石多、难找支点的建议用角度大些的17/18号（说实话，我也喜欢大嘴巴、结石少的老外）；

５－GRACEY-11/12用于后牙近中面，同理可用15/16号；

６－手用器械，最好选用最稳定的口内支点－－离工作牙1～4个位置的牙河面或切缘；做最后一个牙可以选择变异支点（如下图用到左手辅助支点），口外支点；

７－左上后牙，建议医者座位：腭侧9点位，患者头扭向远离医者一侧；颊侧10～11点位，患者头扭向医者一侧；

８－通用型刮治器工作头比较粗大，用于浅和量多的结石；

９－GRACEY-7/8用于后牙颊舌面，这比临面容易许多了；

10-以上是我个人经验之谈，随便一本美国版教科书口径也大致如此。假如用这些还是不好操作，我们再行交流。其实，这是需要大量的训练的，每个医生都有自己不顺手的区域，那就需要在这方面多下功夫，我自己感觉不顺的区是右上后牙区。

以下４图片选自－－Color atlas of dental hygiene Periodontology.作者：Herbert F. Wolf, Thomas M. Hassell, Gail
http://img.dxy.cn/upload/2009/03/27/43676994.jpg 
GRACEY 11/12用于左上后牙（此图显示颊侧）
http://img.dxy.cn/upload/2009/03/27/90881626.jpg 
GRACEY 13/14用于左上后牙（此图显示颊侧）
http://img.dxy.cn/upload/2009/03/27/13499095.jpg 
GRACEY 7/8号用于左上后牙（此图显示颊侧）。

事无巨细，外行看来极其繁琐，但这些是建立在人体工学、询证医学基础上的科学理论；绝大多数外文专业书都是这样要求的，我们可以拿来就用的。

图片选自－－Color atlas of dental hygiene Periodontology.作者：Herbert F. Wolf, Thomas M. Hassell, Gail
http://img.dxy.cn/upload/2009/03/27/30940808.jpg 

中国，最赚钱的正畸、修复科越来越多的到牙周科寻求帮助了。种植牙修复后生物学宽度会被侵犯吗？数千上万元昂贵的全瓷、种植修复，我们提供专门的维护器械和措施了吗？正畸提供专门的牙周护理了吗？保障修复体效果的龈成形术患者做了吗？

国外洁牙师是个低于牙医的热门专业，牙周科专家就更不用说了。2-3度松动牙一定要拔吗？１２ｍｍ牙周袋通过非传统牙周手术达到３ｍｍ——是神话吗？来看Laser-assisted new attachment procedure (LANAP)——激光辅助新附着形成术，您会得到出乎意料的答案。
先看个神奇案例,见视频　：http://www.youtube.com/watch?v=Dd846LBK9GQ
Case from DDS. John（对这个案例感兴趣战友可以搜索该牙医的文章，有这个病例治疗过程的详解）

LANAP简介:Laser-assisted new attachment procedure (LANAP), is a therapy designed for the effective treatment of periodontitis through regeneration rather than resection. This therapy, and the laser which performs it (The PerioLase MVP-7, Millennium Dental Technologies, Inc.) have long been in use by the dental community. LANAP is a U.S. Food and Drug Administration-approved patented protocol for the treatment of periodontitis, or gum disease. LANAP was developed and perfected in Cerritos, California over many years by Dr. Robert H. Gregg II (and Dr. Delwin McCarthy to be patient-friendly, dentist-friendly, effective, and predictable.

激光治疗过程：

A.  Perio probe indicates excessive pocket depth.
B.  Laser light removes bacteria and diseased tissue.
C.  Ultrasonic scaler and special hand instruments are used to remove root surface tarter.
D.  Laser finishes cleaning pocket and aids in sealing the pocket closed so new germs cannot enter.
E.  Healing of gums to clean root surface occurs.
F.  Bite trauma is adjusted.
G.  Healing occurs.
http://img.dxy.cn/upload/2009/04/02/80643818.jpg 
LANAP术后新附着形成组织片。图片选自
Histologic uation of an Nd:YAG laser-assisted new attachment procedure in humans.
Yukna RA, Carr RL, Evans GH.

Int J Periodontics Restorative Dent. 2007 Dec;27http://img.dxy.cn/images/smiles/devil_smile.gif:577-87.

不“开刀”，不植骨，新附着形成了，结果是神奇的，争论也是激烈的（在美国也不乏怀疑者）。我只持中立态度介绍给大家，毕竟是新东西，在pubmed我只搜到LANAP文章５篇；但美国有关牙周病论坛里，认可它的牙医占大多数，很多牙周病专家展示了神话般的病例结果。北美牙周疾病发病率大约是50％（我国根据不同地区报道在80～95％），大众对此非常认真，这为牙周医疗提供了大量客户。所以在美国，开展LANAP业务的牙医和材料商，生意都很红火！
http://img.dxy.cn/upload/2009/04/02/64196857.snap.jpg
（缩略图，点击图片链接看原图）