高齡者牙科診療之輔助

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高齡者口腔醫療照護 Oral care of the elderly patient 高齡者牙科診療之輔助 Dental assistant in geriatric dentistry 牙科診療時的注意事項潔牙時的注意事項課程大綱日本東京醫科齒科大學小兒齒科學博士台北醫學大學口腔醫學院教授台北醫學大學附設醫院牙科部主治醫師 hunghuey@tmu.edu.

1 高齡者口腔醫療照護 Oral care of the elderly patient 高齡者牙科診療之輔助 Dental assistant in geriatric dentistry 牙科診療時的注意事項潔牙時的注意事項課程大綱日本東京醫科齒科大學小兒齒科學博士台北醫學大學口腔醫學院教授台北醫學大學附設醫院牙科部主治醫師蔡恒惠 Hung-Huey Tsai 1 Hung-Huey Tsai 2 學習臨床跟診技巧學習潔牙技巧學習目的資料來源 1. 最新歯科衛生士教本高齢者歯科森戸光彦向井美惠植松宏ほか著医歯薬出版株式会社 2. スペシャルニーズデンティストリー障害者歯科日本障害者歯科学会編医歯薬出版株式会社 3.DVD 版動画でマスターリハビリテーション口腔ケア摂食嚥下障害, 要介護者へのアプローチ金子芳洋監修 / 小林直樹企画制作医歯薬出版株式会社 Hung-Huey Tsai 3 Hung-Huey Tsai 4 Vital sign 監視時應注意事項高齡者的脈搏比一般成人快或慢? 高齡者脈搏的異常值? 模不到脈搏時如何處理? 血壓血壓隨著年齡的變化? 姿勢與血壓 ( 收縮壓舒張壓 ) 的關係? 血壓與脈搏的關係? 呼吸比一般成人快或慢? 次數增加且呼吸較淺表示? 體溫比一般成人高或低? 如何測量側臥者腦中風 ( 單邊麻痺 ) 者的體溫? 血氧濃度血氧濃度的異常值? 心電圖不正常的波型? Hung-Huey Tsai 5 Hung-Huey Tsai 6 1

2 高血壓患者診療時應注意事項放鬆下監視 vital sign 去除不安恐懼感使用表面麻醉拔牙時血壓平均會上升多少? 血壓上升與出血的關係? 降血壓藥的服用? 鈣離子阻斷劑的副作用 ( 頭暈頭痛浮腫臉部紅潮牙齦腫脹 ) 心臟病患者診療時應注意事項牙科治療容易使心跳血壓?( 精神壓力 ) 心臟病容易在一天內的幾時發作? 因此約診的安排最好在? Hung-Huey Tsai 7 Hung-Huey Tsai 8 狹心症 ( 冠狀動脈疾病 ) 心肌突然短暫的缺氧和缺血所引起絞痛的疾病於胸骨下胸骨後或心前區產生短暫陣發性之疼痛, 感到像脹氣疼痛心燒灼感很重的東西壓在胸口上或類似針扎的嚴重胸痛感持續時間約 5 分鐘患者需隨身攜帶硝酸甘油舌下含片, 以便心絞痛發作時使用心肌梗塞指冠狀動脈突然受到阻塞, 造成供應心肌的血流及氧氣因此而中斷, 最後引發心肌壞死, 而且死亡的機率極高持續時間約 30 分鐘以上曾經發作過的患者, 發作後 6 個月內不要 scaling 服用抗凝血藥牙周敷藥 Hung-Huey Tsai 9 Hung-Huey Tsai 10 心律調節器 (Pacemakers) 在台灣至少有超過四萬以上的人口身上裝有心律調節器遇有強大的磁場, 電場或電磁場都會影響它正常的功能超音波電刀 Endometer EPT 腦血管疾病 ( 中風 ) 缺血性 (60%) 腦動脈本身的病變如腦動脈硬化, 致使局部腦動脈管腔變窄或完全阻塞, 或形成血栓, 造成該部腦血流供應中斷, 出現腦組織的軟化壞死出血性 (40%) 長期血壓升高, 腦部硬化的小動脈形成了粟粒大小的動脈瘤, 當血壓突然升高引起動脈瘤破裂, 於是發生腦出血病情比較嚴重膀胱膨脹容易讓血壓上升 Hung-Huey Tsai 11 Hung-Huey Tsai 12 2

3 呼吸器疾病共同的症狀為? 治療時對病患較好的姿勢為? 輕微的刺激就可能引發咳嗽咳嗽後會用力吸氣, 須注意器械等異物的吸入氣喘的患者須注意哪些事項? 服用藥 ( 類固醇支氣管擴張劑 ) 氧氣誘發因子 ( 脫水味道刺激唾液管感冒 ) 糖尿病口腔酸鹼值偏向? 唾液分泌量? 容易出血不容易止血空腹時血糖值會?(60mg/dl 以下 ) 治療時間應選在? 注意 HbA1C( 醣化血色素 ) 值血糖值只代表抽血當時的血糖狀態, 而較長時期的血糖控制情形, 則須靠 HbA1C 來反映糖尿病患者若能將 HbA1C 控制在 8% 以內, 不只可以減少併發症, 也能減緩已存在併發症的惡化 Hung-Huey Tsai 13 Hung-Huey Tsai 14 徵兆記憶減退影響到工作無法勝任原本熟悉的事務言語表達出現問題喪失對時間地點的概念判斷力變差警覺性降低抽象思考出現困難東西擺放錯亂行為與情緒出現改變個性改變活動及開創力喪失失智症退化性失智症阿茲海默症最常見記憶功能障礙認知功能喪失額顳葉型失智症人格行為變化路易氏體失智症動作變慢肢體僵直顫抖認知功能減退視幻覺血管性失智症腦血管疾病所引起其他失智症甲狀腺功能低下腦瘤腦炎 AIDS 外傷酒癮正常腦壓水腦 Vit.B12 缺乏失智症與攝食阿茲海默症認知期的問題, 異食症額顳葉型失智症吃得很快, 容易噎到路易氏體失智症無法順利將食物放入口內血管性失智症攝食障礙吞嚥障礙 Hung-Huey Tsai 15 Hung-Huey Tsai 16 失智症不要正面否定患者不要指責患者與照護者溝通與患者一起做 ( 做給他看 ) 假牙上標記號與名字配合患者視線的高度特徵自責焦慮疲倦專注力下降對過去的事情一直有內疚或後悔對任何事情都覺得煩躁潔牙指導會造成心理負擔憂鬱症接觸方法發問用 open question( 不要用 closed question) 先聽患者講話講話不要太快聲音不要太大不可以說加油! 要刷牙! 考慮個人隱私 Hung-Huey Tsai 17 Hung-Huey Tsai 18 3

牙科診療時的注意事項聽力姿勢 ( 坐姿腰靠 ) 嘴唇口腔黏膜牙根鏡子 ( 反射鏡放大鏡 ) 印模 ( 先下後上 ) 治療時間潔牙時的注意事項如何選擇牙刷刷牙的方式動搖牙齒的清潔最後臼齒遠心面的清潔單顆牙的清潔睡眠時的假牙 Hung-Huey Tsai 19 Hung-Huey Tsai 20 較不推薦的牙刷動物毛豬毛, 比尼龍不容易乾, 較不衛生超細刷毛

4 牙科診療時的注意事項聽力姿勢 ( 坐姿腰靠 ) 嘴唇口腔黏膜牙根鏡子 ( 反射鏡放大鏡 ) 印模 ( 先下後上 ) 治療時間潔牙時的注意事項如何選擇牙刷刷牙的方式動搖牙齒的清潔最後臼齒遠心面的清潔單顆牙的清潔睡眠時的假牙 Hung-Huey Tsai 19 Hung-Huey Tsai 20 較不推薦的牙刷動物毛豬毛, 比尼龍不容易乾, 較不衛生超細刷毛牙周囊袋 (4mm) 山型 (V 型波浪型 )? 毛尖端球型 Shape of toothbrush head Conventional All conventional toothbrush head designs are effective in cleansing every tooth surface. 一般牙刷毛的粗細 0.2mm Diamond shape The tips of these toothbrush heads are narrower than those of the conventional ones. These tips are designed for easy access to posterior teeth. Hung-Huey Tsai 21 Hung-Huey Tsai 22 Size of toothbrush head 0-2 years Brush head size should be approximately the diameter of a Hong Kong 10-cent coin (~15mm). 2-6 years Brush head size should be approximately the diameter of a Hong Kong 20-cent coin (~19mm).(1 元銅板 ) Size of toothbrush head 6-12 years Brush head size should be approximately the diameter of a Hong Kong 50-cent coin (~22mm). (5 元硬幣 ) 12 years and above Brush head size should be approximately the diameter of a Hong Kong one-dollar coin (~25mm).(10 元硬幣 ) Hung-Huey Tsai 23 Hung-Huey Tsai 24 4

Bristle pattern Block pattern The bristles are of the same length and are arranged neatly like a block.

PBI(Poly benz imidazol) 不易吸水耐高低溫耐用 Wavy or V-shape pattern The bristles form a V- shape or wavy pattern.

claimed by the manufacturer that their bristles will naturally be pointing at the gum line at a 45 degree angle.

5 Bristle pattern Block pattern The bristles are of the same length and are arranged neatly like a block. 牙刷毛的材質聚醯胺纖維 (Nylon) 聚酯纖維 (Polyester Fiber) PBT(Polybutylene terephtthalate) PTT(Polytrimethylene terephthalate) PBI(Poly benz imidazol) 不易吸水耐高低溫耐用 Wavy or V-shape pattern The bristles form a V- shape or wavy pattern. According to the manufacturer, this is intended to give the bristles a better contact with the areas around the adjacent tooth surfaces. Hung-Huey Tsai 25 Hung-Huey Tsai 26 Bristle pattern Advantage If these toothbrushes are used correctly, it is claimed by the manufacturer that their bristles will naturally be pointing at the gum line at a 45 degree angle. It is also suggested that since the bristles at the brush tip are longer, it enables the toothbrush to reach the difficult-to-clean areas. Hung-Huey Tsai 27 Hung-Huey Tsai 28 Straight handle All conventional toothbrushes have straight handles that are easier to control. Handle design Contra-angle handle This handle design is similar to a dental instrument, intending to access to the difficult to clean areas. Flexible handle This kind of handle intends to reduce gum injury caused by excessive brushing force. Handle design Slip prevention grip handle This handle intends to prevent the toothbrush from slipping away during toothbrushing. Hung-Huey Tsai 29 Hung-Huey Tsai 30 5

It is designed to simultaneously clean the outer, inner and chewing surfaces of teeth.

When the brush is placed on the chewing surface, all the three surfaces of the tooth are

Single-tuft toothbrush It is a toothbrush with a very small head which can be used to clean

The cleansing effectiveness of different shapes of the brush head is the same.

劣大橫擦法良馮尼氏法良大 Hung-Huey Tsai 33 Hung-Huey Tsai 34 Blotting method 刷牙方法難易度牙菌斑去除效果

6 It is designed to simultaneously clean the outer, inner and chewing surfaces of teeth. Super brush Three brush heads are combined together in the Superbrush. When the brush is placed on the chewing surface, all the three surfaces of the tooth are cleaned simultaneously. It shortens the brushing time. Single-tuft toothbrush It is a toothbrush with a very small head which can be used to clean wisdom teeth and crooked teeth effectively. There are various shapes of the brush head. The cleansing effectiveness of different shapes of the brush head is the same. Hung-Huey Tsai 31 Hung-Huey Tsai 32 刷牙的力道刷牙方法難易度牙菌斑去除效果牙齦按摩效果牙縫清潔效果牙齒磨耗橫刷法簡單劣劣大直刷法劣大橫擦法良馮尼氏法良大 Hung-Huey Tsai 33 Hung-Huey Tsai 34 Blotting method 刷牙方法難易度牙菌斑去除效果牙齦按摩效果牙縫清潔效果牙齒磨耗貝普難良良少氏通刷牙方法旋轉法難易度牙菌斑去除效果牙齦按摩效果史迪門氏難劣良牙縫清潔效果牙齒磨耗少少 Individual vertical method B 普難良良少 M 通史迪門氏改良難良良稍少 I 普 V 難良劣良通 M 查特氏法難良良良少 Hung-Huey Tsai 35 Hung-Huey Tsai 36 6

7 Hung-Huey Tsai 37 Hung-Huey Tsai 38 4 年後 Hung-Huey Tsai 39 Hung-Huey Tsai 歲 56 歲 1 年後 71 歲 75 歲 Hung-Huey Tsai 41 Hung-Huey Tsai 42 7

8 42 歲 43 歲 6 年後 46 歲 61 歲 Hung-Huey Tsai 43 Hung-Huey Tsai 歲禁菸 6 年 60 歲 73 歲 83 歲 60 歲 83 歲 48 歲 49 歲 6 年後 Hung-Huey Tsai 45 Hung-Huey Tsai 46 高齡者牙科醫療工具方法總結 Hung-Huey Tsai 47 8

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無投影片標題高齡者口腔醫療照護 Oral care of the elderly patient 口臭 BAD BREATH (Halitosis) 日本東京醫科齒科大學小兒齒科學博士台北醫學大學口腔醫學院教授台北醫學大學附設醫院牙科部主治醫師 hunghuey@tmu.edu.tw 蔡恒惠口臭