李德利 医学博士
牙面白垩斑样病损(White spot lesions)是口腔临床常见的一种釉质表面病损,是由于各种病因导致釉质脱矿,釉质内形成大量的微孔样结构,外观呈无光泽的白垩色。研究表明正畸患者在正畸治疗后牙面白垩斑样病损的发生率为49.6% [1-2],且前牙区多见。如若不治疗,牙面白垩斑样病损会进一步发展为釉质龋甚至牙本质龋。
当托槽拆除后,造成釉质脱矿的生物膜环境发生改变,釉质脱矿逐渐停止,此时釉质表面为白垩色的粗糙状,称为活动性白斑[3-4]。活动性白斑由于表层釉质矿化有限,因此树脂渗透治疗相对容易。随着唾液及食物中再矿化离子的不断作用,脱矿的釉质表面逐渐硬化,但是深层的脱矿区依然存在。随着时间的增加,表层脱矿区逐渐加厚,此时当患者口腔卫生状况较好时,随着刷牙等机械性的磨损,表层釉质变得光亮坚硬,逐渐变为静止性白斑[5-6]。当应用氟化物后,表层牙釉质矿化程度加深,进一步阻止了深层脱矿区的再矿化,与此同时,食物中的色素等成分也会随着脱矿的孔隙进入脱矿区,从而形成黄褐色斑块。有研究表明,正畸托槽拆除3个月后,活动性白斑逐渐变为静止性白斑,后者的树脂渗透同前者相比要困难的多。
去除白垩斑病损的方法很多,可以使用再矿化物质进行治疗如CPP-ACP,但是再矿化物质的使用时间较长,需要在早期应用,同时作用往往局限于表层牙釉质,与患者的依从性息息相关,因此难以在较短的时间内改善牙齿的美观。使用盐酸和浮石粉进行釉质表面的微打磨可以有效的去除白垩斑病损[7],但会造成釉质的大量丧失,一次微打磨,将去除0.360mm±0.120mm的牙釉质,相当于1/3厚度的牙釉质。漂白治疗[8-9]可以在一定程度上去除部分白斑,但是作用有限,术后敏感经常发生,同时漂白剂可以造成健康釉质和病损区釉质的脱矿,从而釉质硬度下降。充填和贴面等传统治疗白垩斑病损的方法通常要去除大量的牙体硬组织,由于正畸结束后的患儿正处于青春期,传统修复方法容易使釉质过早的丧失,从而在早期就加速了釉质的破坏。树脂渗透技术重点在于终止病变的发展。有研究表明, 15%的盐酸酸蚀120秒,仅去除30-40um的牙釉质,恰好将表层矿化程度较高的牙釉质去除,因此属于微创治疗[10]。
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