论文题名(中文): | 牙周非手术治疗疗效的影响因素分析及预测模型构建 |
作者: | |
学号: | B1811110535 |
论文语种: | chi |
学科名称: | 医学 - 口腔医学 - 牙周病学 |
学生类型: | 博士 |
学校: | 北京大学医学部 |
院系: | |
专业: | |
第一导师姓名: | |
第二导师姓名: | |
论文完成日期: | 2021-06-01 |
论文答辩日期: | 2021-05-14 |
论文题名(外文): | Influencing factors and prediction model of the effectiveness of non-surgical periodontal treatment |
关键词(中文): | |
关键词(外文): | Non-surgical periodontal treatment ; Local anesthesia ; Prognosis |
论文文摘(中文): |
牙周炎(Periodontitis)是由牙菌斑介导的牙周支持组织的破坏性炎症性疾病。作为世界上最常见的慢性感染性疾病之一,牙周炎是一个全球流行的重大公共卫生问题,也是成人失牙的主要原因。牙周非手术治疗(Non-surgical periodontal treatment, NSPT)是牙周系统治疗的基础,其疗效受到诸多因素的影响。随着爱伤观念及微创治疗理念的提出和发展,越来越多的医师选择在局麻下实施NSPT。然而,不同局麻方式虽可有效缓解患者治疗时的疼痛不适,但其对NSPT临床疗效的影响仍缺乏强有力的理论支持。另外,牙周医师在NSPT过程中对局麻的应用仍以经验为主,关于临界值界定的研究目前尚处于空白。此外,尽管牙周治疗后的结果一般会随着时间的推移保持相对稳定,但仍有少数患者和部位会出现疾病的复发或进展,最终造成牙齿脱落。截至目前,关于中国人群NSPT后牙周炎进展甚至失牙的影响因素及其相应预测模型的研究仍十分有限。 综上,本课题的研究目的包括: 1. 基于电子化牙周信息表中的常用临床数据,评估局部注射麻醉对中国牙周炎患者NSPT短期临床疗效的影响,并确定开始实施局麻的临界探诊深度(probing depth, PD)值,为临床工作提供更准确的理论依据。 2. 结合临床及影像学数据,采用多水平回归模型分析中国重度牙周炎患者经NSPT后长期随访期间牙周炎进展及牙齿缺失的影响因素。 3. 在多水平影响因素分析的基础上,构建适合重度牙周炎人群NSPT后长期随访期间牙周炎进展及牙齿缺失的Nomogram预测模型,帮助临床医师尽早制定合理的治疗方案,并可直观地向患者展示总体及个别牙的预后,有利于医患沟通。 本课题为回顾性队列研究(NSPT短期疗效研究共纳入平均随访6周的3980名牙周炎患者;NSPT长期疗效研究共纳入平均随访11年的131名重度牙周炎患者),结合北京大学口腔医院牙周科电子化信息表中的临床数据以及全口根尖片中的影像学数据,采用多水平线性回归模型(因变量为PD降低值)、多水平Logistic回归模型[因变量为出血指数(bleeding index, BI)是否降低或牙周炎是否进展]和多水平Cox回归模型(因变量为失牙与否)分析评估NSPT疗效或牙周炎进展的影响因素。在多因素回归分析的基础上,构建Nomogram预测模型,并利用受试者工作特征(receiver operating characteristic, ROC)曲线、校准曲线以及决策曲线分析(decision curve analysis, DCA)对预测模型的性能、预测准确性以及净效益进行评估。 在上述研究的基础上,本课题得出以下结果及结论: 1. 本研究中局麻组在NSPT后PD、PD>=5mm百分比、探诊出血(bleeding on probing, BOP)阳性率以及BI>2百分比的降低量较非局麻组更多,且差异具有统计学意义(P<0.001)。这提示局部注射麻醉的实施对中国牙周炎患者NSPT后PD、BI等临床指标的改善有显著的积极影响。 2. 局麻组与非局麻组NSPT后PD降低量的差异在基线PD<7mm时为0.12-0.22mm,而当基线PD>=7mm时两者之间差异增至0.41-1.37mm,提示临床医师在6mm以上位点应实施局麻下机械治疗。 3. 基线PD、附着丧失(attachment loss, AL)、BOP、根分叉病变(furcation involvement, FI)、牙齿动度以及影像学骨吸收量(bone loss, BL)均与中国重度牙周炎人群下颌磨牙的牙齿脱落显著相关。就全口牙位分析而言,性别、糖尿病、吸烟状况、牙齿类型以及基线牙周状况(PD、AL、BOP、牙齿动度和BL)等临床及影像学因素与失牙显著相关。在回归分析基础上分别构建下颌磨牙及全口牙位失牙的Nomogram预测模型,曲线下面积(area under the curve, AUC)分别为0.891和0.860,提示模型预测准确性良好。校准曲线、DCA等验证结果也显示模型预测性能良好。 4. 本研究结果显示NSPT对牙周炎症的控制是长期有效的,且基线PD越大,治疗后PD改善越明显,深袋百分比亦由基线时的59.9%降至最后一次复诊时的40.1%,且差异具有统计学意义(P<0.0001)。 5. 重度吸烟状况,磨牙牙位,基线PD、AL和BL等因素与NSPT后牙周炎进展显著相关,并依此构建了相应的Nomogram预测模型。结果表明在磨牙和牙周破坏更重的位点存在更高的牙周炎复发或进展风险,提示临床医师需要更加重视这些部位的定期复查和维护。 本课题的创新性在于本研究整合分析了中国牙周炎人群临床及影像学数据资料,进一步分析评估NSPT疗效的影响因素及长期随访过程中牙周炎进展甚至失牙的影响因素,不仅首创了根分叉区骨吸收量的影像学测量分析方法,同时在口腔领域首次利用Nomogram构建了重度牙周炎患者NSPT后长期随访过程中牙周炎进展及失牙的预测模型。 上述研究结果为探索中国牙周炎人群NSPT短期及长期疗效的影响因素提供了一定的证据支持,构建的Nomogram预测模型为临床医师制定合理治疗计划提供了直观简便的新颖思路,对于未来牙周炎的个性化预后判断和治疗,均具有十分重要的临床参考价值。 |
文摘(外文): |
Periodontitis is a destructive inflammatory disease of periodontal supportive tissues that is initially mediated by dental plaque. As one of the most common chronic infectious diseases in the world, periodontitis is a major public health problem and main cause of tooth loss. Non-surgical periodontal treatment (NSPT) is the basis of periodontal treatment, and the effectiveness of it may be influenced by many factors. With the proposal and development of the patient-friendly conscience, more and more people choose to perform local anesthesia (LA) during scaling and root planing (SRP) to relieve the pain and discomfort of patients. However, there is little evidence of the effects of LA on clinical outcomes of NSPT, in particular among Chinese. Besides, the application of LA by periodontists during SRP is mainly based on their experience, and the research on the definition of the threshold is still limited. In addition, although the outcome after NSPT can remain relatively stable over time, there are still a few patients and sites may experience recurrence or progression of the disease, resulting in tooth loss eventually. Up to now, there is quite limited research on the influencing factors and corresponding prediction models of periodontal progression and tooth loss after NSPT in Chinese population. The purposes of the present study include: To evaluate the effect of LA on short-term clinical outcomes of NSPT, and to determine the circumstances under which LA should be prescribed during SRP. To analyze the influencing factors of periodontal progression and tooth loss in Chinese patients with severe periodontitis during long-term follow-up period after NSPT by multivariate regression analyses. To develop suitable nomogram prediction models of periodontal progression or tooth loss after NSPT among Chinese patients with severe periodontitis by comprehensively analyzing clinical and radiographic influencing factors. This is a retrospective cohort study. 3980 patients with periodontitis were enrolled in the short-term effectiveness of NSPT study, while 131 patients with severe periodontitis were selected within a mean follow-up period of 11 years in the long-term effectiveness of NSPT study. The associations of influencing factors including clinical and radiographic parameters with periodontal progression or tooth loss were assessed using multilevel linear regression, Logistic regression and Cox regression analyses. Corresponding nomogram prediction models were developed, and the validation and discriminatory ability of them were evaluated by receiver operating characteristic (ROC) curve, calibration curve and decision curve analysis (DCA). The main results and conclusions are as follows: 1. A significantly higher mean decrease in probing depth (PD) after NSPT was found in the LA group than in the no local anesthesia (NLA) group (0.98mm vs. 0.54mm, P<0.001). A significantly higher probability of decreases was found in the LA group in bleeding index (BI) (percentages of teeth with BI>1 and BI>2) (16.7% vs. 13.8%, P<0.001; 34.7% vs. 28.1%, P<0.001). Thus, LA improved the decrease in PD and BI after NSPT. 2. The difference between LA group and NLA group was 0.12mm to 0.22mm for sites with baseline PD<7mm; however, it increased to 0.41mm to 1.37mm for sites with baseline PD>=7mm, which suggesting that the clinician can perform SRP under routine LA at sites with PD>=7mm. 3. PD, attachment loss (AL), furcation involvement (FI), bleeding on probing (BOP), tooth mobility and radiographic bone loss (BL) were significantly associated with mandibular molar loss in Chinese patients with severe periodontitis (P<0.01). In terms of full-mouth analysis, gender, diabetes mellitus, smoking status, molar and baseline periodontal parameters (PD, AL, BOP, tooth mobility and BL etc.) were significantly associated with tooth loss. Corresponding nomogram prediction models were developed on the basis of above analyses, and the area under the curve (AUC) was 0.891 and 0.860 respectively. Calibration curve and DCA showed that the performance of models was good. 4. The results of the present study showed that NSPT was effective for a long time. The deeper the baseline pocket depth was, the more improvement of PD would be in the end. The percentage of deep pocket (PD>6mm) decreased from 59.9% at baseline to 40.1% at the last visit, and the difference was statistically significant (P<0.0001). 5. Heavy smoking status, molar, PD, AL and BL were significantly associated with the progression of periodontitis after NSPT, and a corresponding nomogram was constructed. The results showed that there was a higher risk of recurrence or progression of periodontitis in molars and periodontitis-related sites, suggesting that clinicians should pay more attention to the regular re-examination and maintenance of these sites. Based on the clinical and radiographic data of Chinese patients with periodontitis, the present study further evaluated the factors influencing the short-term and long-term effectiveness of NSPT. The strength of this study lies in the innovation of the nomogram prediction models of periodontal progression and tooth loss in patients with severe periodontitis, which were not used in the field of periodontology before. In addition, this study first determined the circumstances under which local anesthesia should be prescribed during NSPT, and pioneered the method of radiographic measurement in the furcation region. The above results provide certain evidence for exploring the factors influencing the effectiveness of NSPT among Chinese patients with periodontitis. The constructed nomogram prediction models can provide an effective tool and novel concept for clinicians to make personalized prognosis judgement and reasonable treatment plans. |
论文目录: |
第一章 文献综述 1
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1.1 牙周非手术治疗疗效的影响因素 1 1.1.1 年龄 1 1.1.2 性别 2 1.1.3 种族及遗传因素 3 1.1.4 吸烟 4 1.1.5 全身情况 6 1.1.6 依从性 7 1.1.7 解剖因素 8 1.1.8 患牙基线牙周状况 10 1.1.9 牙齿类型 11 1.1.10 医生因素 12 1.2 失牙 13 1.2.1 失牙的危害 14 1.2.2 失牙的影响因素 15 1.3 预测模型 16 1.4 小结 17 第二章 引言 18 第三章 局麻对牙周非手术治疗短期疗效的影响 22 3.1 研究目的 22 3.2 材料和方法 22 3.2.1 研究人群 22 3.2.2 效应指标 22 3.2.3 牙周检查和治疗 24 3.2.4 统计分析 24 3.3 结果 24 3.3.1 研究人群基线特征 24 3.3.2 患者水平治疗前后临床指标的变化 24 3.3.3 局麻对牙周非手术治疗临床疗效的影响 26 3.4 讨论 32 3.5 结论 36 第四章 NSPT后下颌磨牙失牙的影响因素分析及预测模型构建 37 4.1 研究目的 37 4.2 材料和方法 37 4.2.1 研究人群 37 4.2.2 临床指标 37 4.2.3 影像学指标 39 4.2.4 统计分析 40 4.3 结果 41 4.3.1 研究人群基线特征 41 4.3.2 失牙组与非失牙组基线状况对比 41 4.3.3 NSPT后下颌磨牙缺失的单因素分析 41 4.3.4 NSPT后下颌磨牙缺失的多因素分析 45 4.3.5 NSPT后下颌磨牙存留情况的Nomogram预测模型构建与验证 45 4.3.6 NSPT后下颌磨牙存留情况Nomogram预测模型的应用示例 46 4.4 讨论 46 4.5 结论 54 第五章 NSPT后疾病进展的影响因素分析及预测模型构建 55 5.1 研究目的 55 5.2 材料和方法 55 5.2.1 研究人群 55 5.2.2 临床指标 55 5.2.3 影像学指标 56 5.2.4 统计分析 56 5.3 结果 57 5.3.1 研究人群基线特征 57 5.3.2 T0至T1期患者牙周炎分期分级的变化 57 5.3.3 失牙组与非失牙组基线状况对比 59 5.3.4 失牙组牙位分布情况 62 5.3.5 失牙组失牙原因分类情况 62 5.3.6 牙齿缺失的单因素分析 62 5.3.7 牙齿缺失的多因素分析 65 5.3.8 牙齿存留情况的Nomogram预测模型构建与验证 70 5.3.9 NSPT前后余留牙齿牙周状况变化 71 5.3.10 NSPT后余留牙齿牙周炎进展因素分析 73 5.3.11 NSPT后余留牙齿牙周炎进展Nomogram预测模型构建与验证 75 5.4 讨论 75 5.5 结论 81 第六章 结论及展望 83 参考文献 85 致谢 106 北京大学学位论文原创性声明和使用授权说明 108 学位论文答辩委员会名单 109 个人简历、在学期间发表的学术论文与研究成果 110 |
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分类号: | R781.4 |
馆藏位置: | 医临时馆 |
开放日期: | 2023-04-07 |