Käypä hoito

Parodontiitti

Käypä hoito
11.10.2016
Suomalaisen Lääkäriseuran Duodecimin ja Suomen Hammaslääkäriseura Apollonia ry:n asettama työryhmä

Opi ja ota käyttöön

Koosteet

Potilaalle

Muut suositukset

Miten viitata Käypä hoito -suositukseen? «»1

Keskeinen sanoma

  • Parodontiitti eli hampaan kiinnityskudosten sairaus on merkittävä kansantauti. Yleisimmin kyseessä on krooninen parodontiitti, joka on väestössä alidiagnosoitu ja jää sen takia osin hoitamatta.
  • Gingiviitin eli ientulehduksen ehkäisy ja hoito ovat keskeinen osa parodontiitin ehkäisyä.
  • Parodontiitin varhaisdiagnostiikkaan ja hoitoon on perusterveydenhuollossa kohdistettava erityistä huomiota, sillä vaikea parodontiitti ja sen seuraukset aiheuttavat huomattavia kustannuksia ja vaativat usein erikoishammaslääkäritasoista hoitoa.
  • Parodontiittiriskin toteaminen edistää ehkäisyn ja hoidon kohdentamista.
  • Parodontologinen tutkimus, johon kuuluu olennaisesti ientaskumittaus, on osa suun terveydentilan tutkimusta ja sisältää myös peri-implanttikudosten tutkimisen. Tutkimus pitää tehdä kaikenikäisille säännöllisin väliajoin, jotta hampaita ja hammasimplantteja ympäröivien kudosten sairaudet todetaan mahdollisimman varhaisessa vaiheessa.
  • Hammaslääkäri vastaa diagnostiikasta, hoidon suunnittelusta ja sen toteutuksesta.
  • Kun sairaus on diagnosoitu, se hoidetaan viipymättä. Vaikuttava hoito on toteutettavissa tehokkaasti lyhyellä aikavälillä.
  • Tärkeä osa hoitoa ovat omahoidon ohjaus, potilaan sitouttaminen hoitoon ja tarvittaessa tupakkatuotteista vieroitus.
  • Hyvän ja pysyvän hoitotuloksen edellytyksenä on potilaan toimiva omahoito.
  • Ylläpitohoito on olennainen osa kiinnityskudos- ja peri-implanttisairauksien hoitoa.
  • Terveet hampaan kiinnityskudokset ovat tärkeä osa yleisterveyttä.

Aiheen rajaus

Tavoitteet

  • Suosituksen tavoitteina on
    • kiinnittää huomiota erityisesti parodontiitin ehkäisyyn, varhaisdiagnostiikkaan ja -hoitoon
    • kiinnittää huomiota myös hammasimplantteja ympäröivien kudosten terveydentilaan
    • luoda hyvin toimivia hoitokäytäntöjä perusterveydenhuoltoon
    • lisätä tietoisuutta hampaan kiinnityskudos- ja peri-implanttisairauksista, jotta ihmiset osaisivat hakeutua riittävän ajoissa hoitoon ja pystyisivät toimimaan aktiivisesti osana hoitotiimiä
    • lisätä tietoisuutta parodontiitin vaikutuksista yleissairauksiin.

Kohderyhmät

  • Suosituksen kohderyhminä ovat
    • hammaslääkärit, suuhygienistit ja muu suun terveydenhuollon ammattihenkilöstö
    • muut terveydenhuollon ammattihenkilöt (mm. lääkärit, neuvola- ja kouluterveydenhoitajat, opiskeluterveydenhuolto, työterveyshuolto, diabeteshoitajat, vanhusten hoivatyötä tekevät)
    • potilasyhdistykset, kuten sydän-, diabetes- ja reumayhdistykset
    • muu väestö.

Määritelmät

Esiintyvyys

Altistavat tekijät

Taulukko 1. Krooniselle parodontiitille ja sen uusiutumiselle altistavia ja syytekijöitä
Väestö- ja/tai yksilötasoHampaisto- ja/tai hammastaso

Lisäksi parodontiitin uusiutumiseen vaikuttavat
Taulukko 2. Peri-implanttisairauksille altistavia ja syytekijöitä
Väestö- ja/tai yksilötaso Hampaistotaso

Diagnostiikka

Tavoite

  • Diagnostiikan tavoitteena on tunnistaa jo varhaisvaiheessa
    • tulehduksen merkit (ienverenvuoto, punoitus, turvotus) hampaita ja hammasimplantteja ympäröivissä kudoksissa
      • gingiviitti: ienverenvuoto taskumittauksen yhteydessä (bleeding on probing, BOP)
      • peri-implanttimukosiitti: ienverenvuoto taskumittauksen yhteydessä implanttia ympäröivässä pehmytkudoksessa
    • kiinnityskato
      • parodontiitti: kliinisesti syventyneitä ientaskuja ja röntgenkuvissa havaittavaa alveoliluukatoa
      • peri-implantiitti: kliinisesti suurentunut taskusyvyys ja röntgenkuvissa havaittava alveoliluukato verrattuna implanttikruunun valmistumisvaiheen mittauksiin
    • taudin uusiutuminen (BOP, syventyneitä ientaskuja ja kiinnityskadon eteneminen) hoidetulla parodontiittipotilaalla.

Oireet

Esitiedot

Kliininen tutkimus

Kuvantamistutkimukset

Mikrobiologiset tutkimukset

Muut diagnostiset tutkimukset

Keskeiset diagnoosit

Taulukko 3. Yleisimpien parodontaali- ja peri-implanttisairauksien diagnoosit sekä niihin liittyvät löydökset «Derks J, Tomasi C. Peri-implant health and disease. A systematic review of current epidemiology. J Clin Periodontol 2015;42 Suppl 16:S158-71 »8, «Sanz M, Bäumer A, Buduneli N ym. Effect of professional mechanical plaque removal on secondary prevention of periodontitis and the complications of gingival and periodontal preventive measures: consen»54, «Lindhe J, Meyle J, Group D of European Workshop on Periodontology. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol 2008;35:282-5 »69, «American Academy of Periodontology Task Force Report on the Update to the 1999 Classification of Periodontal Diseases and Conditions. J Periodontol 2015;86:835-8 »87, «Tonetti MS, Claffey N, European Workshop in Periodontology group C. Advances in the progression of periodontitis and proposal of definitions of a periodontitis case and disease progression for use in »88, «Page RC, Eke PI. Case definitions for use in population-based surveillance of periodontitis. J Periodontol 2007;78:1387-99 »89, «Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol 2008;35:286-91 »90. Taulukon tulostettava versio: «»1
- = pintakohtaisesti negatiivinen löydös
+ = pintakohtaisesti positiivinen löydös
*) = Kun BOP < 15 %, kyseessä on paikallinen gingiviitti.
**) = Vaikka hoidetulla parodontiittipotilaalla olisi luukatoa ja kiinnityskatoa, diagnoosina voi olla gingiviitti, jos syventyneitä ientaskuja ei esiinny.
***) = prosentuaalinen osuus juuren pituudesta
Kliiniset löydöksetRadiologiset löydökset
DiagnoositICD-10ErityispiirteetIenverenvuoto (BOP %)TaskusyvyydetKiinnityskatoLuukato
PARODONTAALISAIRAUDETK05
Krooninen gingiviittiK05.1Ikenen punoitus ja turvotus mahdollista> 15 % *)≤ 4 mm -**) -**)
Krooninen parodontiittiK05.3Ikenen punoitus ja turvotus mahdollista> 15 %≥ 4 mm++
KomplisoitumatonK05.30Ei komplisoivia tekijöitä> 15 %≥ 4 mm++
KomplisoitunutK05.31Esim. tupakointi ja diabetes komplisoivat> 15 %≥ 4 mm++
Taudin vaikeusaste:
lievä +4 mm1–2 mm≤ 15 %***) tai 2–3 mm
keskivaikea+5–6 mm3–4 mm> 15–30 %***) tai 4–5 mm
vaikea+≥ 7 mm≥ 5 mm> 30 %***) tai > 5 mm
Taudin yleisyys:
paikallistunut muoto≤ 30 % hampaista affisioitunut
yleistynyt muoto> 30 % hampaista affisioitunut
Aggressiivinen parodontiittiK05.4Nopeasti edennyt kudostuho+≥ 4 mm++
paikallistunut muotoKiinnityskatoa ≥ 2 pysyvässä hampaassa, joista toisen on oltava molaari+≥ 4 mm++
yleistynyt muotoKiinnityskatoa ≥ 3 muussa hampaassa kuin kuutosissa tai inkisiiveissä+≥ 4 mm++
PERI-IMPLANTTISAIRAUDETT84
Peri-implanttimukosiittiT84.60Ikenen punoitus ja turvotus mahdollista+< 5 mm--
Peri-implantiittiT84.62Ikenen punoitus, turvotus ja märkävuoto ientaskusta mahdollista+≥ 5 mm++

Erotusdiagnostiikka

Ehkäisy

Kroonisen gingiviitin ja peri-implanttimukosiitin hoito

Kroonisen parodontiitin hoito

Hoidon komplikaatioita

Hoitotuloksen arviointi

  • 4–6 viikon kuluttua aktiivisen hoidon päättymisestä tehdään uusi parodontologinen tutkimus ja rekisteröidään saavutettu hoitotulos:
    • omahoidon toimivuus (plakin määrä ja paikantuminen)
    • tupakointitottumusten muutokset
    • ienrajan kulku
    • ientaskujen syvyydet
    • BOP, muut tulehduksen merkit ja furkaatiovauriot
    • hampaiden liikkuvuus.
  • Lisäksi arvioidaan mahdollinen lisähoidon tarve. Arvion perusteena ovat BOP-arvo (≥ 20 %), jäännöshammaskiven esiintyminen ja jäännöstaskujen (≥ 5 mm) lukumäärä.

Ylläpitohoito ja ajoitus

Tiimityö parodontologisessa hoidossa

  • Potilaan ja hammaslääkärin ohella parodontologisen hoitotiimin jäseniä voivat olla suuhygienisti, hammashoitaja ja erikoishammaslääkäri.
  • Potilaan omahoito ja sitoutuminen hoitoon ovat parodontologisen hoidon onnistumisen edellytys. Joissakin tapauksissa (esim. laitoshoidossa olevan potilaan) huoltaja tai omahoitaja avustaa omahoidossa.
  • Hammaslääkäri tekee parodontologisen diagnoosin ja laatii sen perusteella hoitosuunnitelman.
  • Hammaslääkäri osallistuu hoitoon ja vastaa aina sen toteutumisesta kokonaisuutena.
  • Suuhygienisti huolehtii suun terveyden ylläpitämisestä ja osallistuu hoitoon ja ylläpitohoitoon.
  • Jos tarvittavat hoitotoimenpiteet menevät oman osaamisalueen ulkopuolelle, potilas on ohjattava jatkohoitoon.
  • Säännöllisestä ylläpitohoidosta huolimatta etenevä tai uusiutuva parodontiitti (10–20 %:lla potilaista) edellyttää erikoishammaslääkäritasoista hoitoa «Pastagia J, Nicoara P, Robertson PB. The effect of patient-centered plaque control and periodontal maintenance therapy on adverse outcomes of periodontitis. J Evid Based Dent Pract 2006;6:25-32 »156.
  • Potilas lähetetään parodontologiseen hoitoon perehtyneelle (erikois-)hammaslääkärille, kun kyseessä on
    • vaikea parodontiitti, jossa toimenpiteet ovat erittäin vaativia (syvät taskut, furkaatiovauriot, vaikeapääsyiset pinnat)
    • parodontiitti, jossa purenta tai endodonttiset ongelmat ovat osana etiologiaa
    • yleissairauden komplisoima parodontiitti
    • vaikea nuoruusiän parodontiitti
    • vaativaa parodontaalikirurgista hoitoa tarvitseva potilas
    • peri-implantiitti
    • tilanne, jossa asianmukaisen hoidon jälkeen on merkkejä aktiivisesta sairaudesta.
  • Ks. myös kuva työnjaosta «Tiimityö parodontologisessa hoidossa»1.

Parodontiitin yhteys yleissairauksiin

Kustannusasiat

Suomalaisen Lääkäriseuran Duodecimin ja Suomen Hammaslääkäriseura Apollonia ry:n asettama työryhmä

Parodontiitti-suosituksen historiatiedot «Parodontiitti, Käypä hoito -suosituksen historiatiedot»5

Puheenjohtaja:

Eija Könönen, parodontologian professori, HLT, EHL, ylihammaslääkäri, oraalimikrobiologian dosentti; Turun yliopiston hammaslääketieteen laitos, Turun sosiaali- ja terveystoimi

Jäsenet:

Mervi Gürsoy, HLT, EHL, yliopisto-opettaja; Turun yliopiston hammaslääketieteen laitos

Erja Nuutinen, TtM, lehtori; Metropolia ammattikorkeakoulu

Marja Pöllänen, HLT, EHL; Suomalainen Lääkäriseura Duodecim (Käypä hoito -toimittaja)

Kimmo Suomalainen, parodontologian dosentti, HLT, EHL, ylihammaslääkäri; Tampereen yliopistollinen sairaala

Pekka Ylöstalo, kliinisen hammashoidon professori, ylihammaslääkäri, parodontologian ja geriatrisen hammaslääketieteen professori; Itä-Suomen yliopisto, Kuopion yliopistollinen sairaala, Oulun yliopisto ja Oulun yliopistollinen sairaala

Sidonnaisuudet

Mervi Gürsoy: Ei sidonnaisuuksia

Eija Könönen: Ei sidonnaisuuksia

Erja Nuutinen: Ei sidonnaisuuksia

Marja Pöllänen: Luentopalkkio (Novo Nordisk, MSD)

Kimmo Suomalainen: Osakeomistus (Orion Oyj)

Pekka Ylöstalo: Ei sidonnaisuuksia

Kirjallisuusviite

Parodontiitti (online). Suomalaisen Lääkäriseuran Duodecimin ja Suomen Hammaslääkäriseura Apollonia ry:n asettama työryhmä. Helsinki: Suomalainen Lääkäriseura Duodecim, 2016 (viitattu pp.kk.vvvv). Saatavilla internetissä: www.kaypahoito.fi

Tarkemmat viittausohjeet: «http://www.kaypahoito.fi/web/kh/viittaaminen»7

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta ja hoidosta hoitopäätöksiä tehtäessä.

Tiedonhakukäytäntö

Systemaattinen kirjallisuushaku on hoitosuosituksen perusta. Lue lisää artikkelista khk00007

Kirjallisuutta

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