LI NI U

Bnh rng ming l bnh ph bin ti nc ta v trn th gii, gy nh hng ln n sc kho con ngi v s pht trin chung v vn ho kinh t - x hi. Bo v sc kho v d phng bnh rng ming l mt nhim v quan trng ca ngnh y t. Nhm trang b cho sinh vin y khoa v kin thc, k nng c bn v thi cn thit p ng c nhu cu y t a phng v quc gia trong giai on hin nay, Khoa Rng Hm Mt Trng i hc Y Dc, i hc Hu s dng gio trnh Rng Hm Mt lm ti liu ging dy o to bc s a khoa h su nm v h bn nm, ng thi lm ti liu tham kho cho mt s i tng khc. Gio trnh ny c tp th ging vin ca khoa bin son, chnh sa v b sung. Ni dung gio trnh thng nht vi cun Sch Xanh ca B Y T xut bn 2006, xc nh cc kin thc, thi v k nng cn t khi tt nghip bc s y khoa. Chng ti xin chn thnh cm n Ban Gim c i hc Hu, Ban Gim Hiu, Phng o To i Hc v ton th cn b ging dy Khoa Rng Hm Mt Trng i Hc Y Dc Hu, gip chng ti hon thnh gio trnh ny. Chng ti xin hoan nghnh tip th mi kin ng gp ca cc ng nghip v cc bn sinh vin gio trnh ny ngy cng hon thin hn. Trng Ban Bin tp Trng Khoa Rng Hm Mt TS.BSCKII NGUYN TOI

BAN BIN TP
1. 2. 3. 4. 5. TS.BSCKII Nguyn Toi ThS.BSCKI L Hng Lin ThS.BSCKI Nguyn Thc Qunh Hoa ThS.BSCKI Trn Thanh Phc ThS.BSCKI V Th Bc Hi Ging vin chnh (GVC) GVC GVC GVC GVC

CH BIN: TS.BSCKII NGUYN TOI NHNG NGI BIN SON: ThS.BSCKI L HNG LIN ThS.BSCKI NGUYN THC QUNH HOA ThS.BSCKI TRN THANH PHC ThS.BSCKI V TH BC HI

Ging vin chnh Ging vin chnh Ging vin chnh Ging vin chnh Ging vin chnh

Chng I

RNG V B RNG
Mc tiu hc tp 1. Phn bit v gi chnh xc tn tng rng theo danh php quc t. 2. M t cc phn v cu trc ca rng. 3. Phn bit c rng sa v rng vnh vin.

1. CC B RNG
1.1. B rng sa Rng sa c vai tr rt quan trng trong: - Tiu ho: nhai nghin thc n. - Gi khong cho rng vnh vin. - Pht m v thm m. - ng thi, kch thch s pht trin ca xng hm nht l s pht trin chiu cao cung rng qua hot ng nhai. B rng sa gm 20 chic. mi phn t hm, c hai rng ca (rng ca gia v rng ca bn), mt rng nanh v hai rng hm / ci (rng ci th nht v rng ci th hai) 1
1: Rng ca gia v rng ca bn trn

2: Rng ca gia v rng ca bn di 3: Rng nanh trn 4: Rng nanh di 5: Rng hm (ci) th nht, th 2 trn 6: Rng hm (ci) th nht, th 2 di.

4 2

5
Hnh 1.1: Rng sa

6 K kiu 1 2 3 4 5

Tn rng Rng ca gia l rng sa s Rng ca bn Rng nanh Rng hm th nht (ci 1) Rng hm th hai (ci 2) 1

1.2. B rng vnh vin Gm 32 chic, mi phn t hm, c hai rng ca (rng ca gia v rng ca bn), mt rng nanh, cc rng ny thay th cho cc rng sa cng tn tng ng; hai rng hm nh (rng hm nh th nht v rng hm nh th hai, thay th cho cc rng hm sa) v ba rng hm ln (rng hm ln th nht, rng hm ln th hai v rng hm ln th ba; cc rng ny khng thay th cho rng sa no c, c bit rng hm ln th nht cn gi l rng-su-tui mc ln rt sm, cng tn ti vi cc rng sa nn rt d nhm vi rng sa v khng chm sc ng mc).

7 5

Hnh 1.2: Rng vnh vin 1: Rng ca gia v rng ca bn trn 2: Rng ca gia v rng ca bn di 3: Rng nanh trn 4: Rng nanh di 5: Rng hm (ci) nh th nht, th hai trn 6: Rng hm (ci) nh th nht, th hai di 7: Rng hm (ci) ln th nht, th hai v rng khn trn 8: Rng hm(ci) ln th nht, th hai v rng khn di

Tn rng Rng ca gia l rng vnh vin s Rng ca bn Rng nanh Rng hm nh th nht (ci nh 1) Rng hm nh th hai (ci nh 2) Rng hm ln th nht (ci ln 1: rng-su-tui) Rng hm ln th hai (ci ln 2: rng-mi-hai-tui) Rng hm ln th ba (ci ln 3: rng khn)

K hiu 1 2 3 4 5 6 7 8

1.3. B rng hn hp Gm rng sa v rng vnh vin cng tn ti trn cung hm trong khong t 6-12 tui.

2. CCH GI TN RNG THEO LIN ON NHA KHOA QUC T (FDI) 10/1970

gi y v gn tn cc rng theo v tr phi tri, trn di, ngi ta dng hai ch s k hiu l xy: 2.1. Ch s u (x) ch vng Rng hai hm c chia thnh 4 vng: 2.1.1. i vi rng vnh vin - Vng 1: cho tt c cc rng hm trn bn phi. - Vng 2: cho tt c cc rng hm trn bn tri. - Vng 3: cho tt c cc rng hm di bn tri. - Vng 4: cho tt c cc rng hm di bn phi. 2.1.2. i vi rng sa - Vng 5: cho tt c cc rng hm trn bn phi. - Vng 6: cho tt c cc rng hm trn bn tri. - Vng 7: cho tt c cc rng hm di bn tri. - Vng 8: cho tt c cc rng hm di bn phi. 2.2. Ch s sau (y) ch loi rng 1 2 87654321 12345678 87654321 12345678 4 3 5 54321 54321 8 6 12345 12345 7

S 1.1: Bn vng ca rng vnh vin

S 1.2: Bn vng ca rng sa.

V d: Gi tn rng hm ln th hai hm trn bn phi vnh vin l rng 17. Gi tn rng hm th nht hm di bn tri sa l rng 74.

3. CC PHN CA RNG
Rng c hai phn: Thn rng v chn rng, c phn cch bi c rng gii phu (ng men-ximng). 3.1. Thn rng l phn trng thy c trn c rng gii phu, thn rng c 5 mt: 3.1.1. Mt nhai (ca rng hm), ra cn (ca nhm rng ca trc): qua , c s tip xc cc rng hm i din cn x, nhai, nghin thc n. mt nhai c cc nm (mi) rng, c phn cch nhau bi cc rnh. 3.1.2. Mt ngoi: cn gi l mt m (hnh lang) i vi rng hm (ci), mt mi (tin nh) i vi rng trc ca. 3.1.3. Mt trong: cn gi l mt vm ming i vi cc rng hm trn, mt li i vi cc rng hm di. 3.1.4. Hai mt bn: mt gn l mt bn ca rng nm gn ng gia, mt xa l mt bn ca rng nm xa ng gia. 3

3.2. Chn rng L phn c cm vo xng rng ca xng hm, c che ph trn cng bi li bm c rng, tn cng bng chp chn rng. S lng chn ty loi rng v v tr ca n. 3.2.1. i vi rng vnh vin - Mt chn: cc rng ca, rng nanh, cc rng hm (ci) nh hm di, rng hm (ci) nh th hai hm trn. - Hai chn: rng hm (ci) nh 1 hm trn (gm mt chn ngoi v mt chn trong), rng hm (ci) ln 1 v rng hm (ci) ln 2 hm di (gm mt chn xa v mt chn gn). - Ba chn: rng hm (ci) ln th nht v th hai hm trn (gm hai chn ngoi v mt chn trong). - S chn bt thng: rng khn v cc trng hp ngoi l cc rng khc c s lng chn thay i. 3.2.2. i vi rng sa - Mt chn: cc rng ca, rng nanh. - Hai chn: cc rng hm (ci) di (gm mt chn xa v mt chn gn). - Ba chn: cc rng hm (ci) trn (gm hai chn ngoi v mt chn trong).

4. CU TRC RNG
Rng c cu to bi ba thnh phn: men, ng v ty rng. 4.1. Men rng Men rng l thnh phn cng nht c th, gm 96% v c, ch yu l Hydroxy apatit, 3% nc, 1% hu c. Men bao ph thn rng, hu nh khng c cm gic. 4.2. Ng rng Ng rng t cng hn men rng, gm 70% v c, 30% hu c v nc, ng lin tc t thn n chn rng, tn cng chp rng (apex), trong lng cha bung ty v ng ty. Ng c cm gic v cha cc ng thn kinh Tomes. Ph mt ngoi ng chn rng l ximng chn rng, c hnh thnh cng vi s hnh thnh chn rng, l ch bm ca dy chng nha chu. 4.3. Ty rng Tu rng l m lng lo trong bung v ng ty, l n v sng ch yu ca rng. Trong ty c mch mu, thn kinh, bch mch...

Men Ng Bung tu ng tu

Chp (Apex)

Hnh 1.3: Cu trc rng

5. PHN BIT RNG SA V RNG VNH VIN

5.1. Thn rng - Thn rng sa thp hn rng vnh vin, kch thc gn-xa ln hn chiu cao. - Mt nhai thu hp nhiu - C rng tht li nhiu v thu hp hn. - Lp men v ng mng hn - Mu rng sng hn, thnh phn v c t hn. - Rng ca v rng nanh sa nh v khng thanh nh rng vnh vin: chiu gn-xa nh hn nhng chiu ngoi-trong phng hn. - Rng hm (ci) sa ln hn rng hm (ci) nh vnh vin, cn phn bit k vi rng hm (ci) ln th nht vnh vin. 5.2. Tu rng - Ty rng sa ln hn nu so theo t l kch thc thn rng. - Sng ty nm gn ng ni men-ng hn. - C nhiu ng ty ph. V vy, khi iu tr su rng sa, cn lu khng lm tn thng ty; khi vim ty th phn ng rt nhanh v d b hoi t. 5.3. Chn rng - Chn rng ca v rng nanh sa di v mnh hn nu so theo t l vi kch thc thn rng. - Chn rng hm sa tch nhau gn c rng hn v cng v pha chp th cng tch xa hn. V vy, chn rng sa d b gy khi nh rng.

Hnh 1.4: S khc bit v hnh th gia rng sa v rng vnh vin A: chiu dy lp men rng sa mng hn B: chiu dy lp ng h rnh rng sa tng i dy hn. C : t l bung tu rng sa ln hn v sng tu nm gn ng ni men ng hn. D: g c rng sa nh cao. E: tr men rng sa nghing v mt nhai F: c rng sa tht li r rt v thu hp hn G: chn rng sa di v mnh hn (so vi kch thc thn rng). H: chn rng hm sa tch ra gn c rng hn v cng gn v pha chp th cng tch xa hn.

CU HI T LNG GI Cu 1. tui 12, c bao nhiu rng vnh vin ? A. 20 D. 28 B. 24 E. 32 C. 26 Cu 2. K hiu ca rng hm (ci) sa th nht hm di bn tri l : A. 54 D. 85 B. 65 E. 55 C. 74 Cu 3. Ch s k hiu v tr ca rng hm trn vnh vin bn phi l: A. 1 D. 4 B. 2 E. 5 C. 3 Cu 4. 74 l k hiu ca rng: A. rng hm (ci) sa th nht hm trn bn phi B. rng hm (ci) sa th hai hm trn bn phi C. rng hm (ci) sa th nht hm di bn tri D. rng hm (ci) sa th hai hm di bn tri E. rng hm (ci) sa th nht hm di bn phi Cu 5. Rng hm (ci) sa th nht hm trn c: A. Hai chn: 1 trong, 1 ngoi D. Ba chn: 2 trong,1 ngoi B. Hai chn: 1 xa, 1 gn E. Ba chn: 2 xa, 1 gn. C. Ba chn: 1 trong, 2 ngoi Cu 6. Rng hm (ci) ln th nht vnh vin hm di c: A. Hai chn: 1 trong, 1 ngoi D. Ba chn: 2 trong, 1 ngoi B. Ba chn: 1 trong, 2 ngoi E. Ba chn: 2 xa, 1 gn. C. Hai chn: 1 xa, 1 gn Cu 7. Thnh phn cu to ca ng rng: A. 96% v c, 4% hu c v nc. D. 30% v c, 70% hu c v nc B. 70% v c, 30% hu c v nc E. 4% v c, 96% hu c v nc. C. 50% v c, 50% hu c v nc. Cu 8. Rng hm (ci) sa c c im: A. Nh hn rng vnh vin thay n D. Ty nh hn rng vnh vin B. Sng ty nm xa ng ni men-ng E. t ng ty ph C. Cc chn rng tch xa nhau pha chp Cu 9. Vim ty rng sa c phn ng rt nhanh v d b hoi t hn rng vnh vin v: A. Thn rng thp hn rng vnh vin D. Ty ln hn B. t ng ty ph E. Rng sa t thnh phn v c hn C. Sng ty nm xa ng ni men-ng Cu 10. Rng sa no c kch thc ln hn rng vnh vin thay th n: A. Rng ci D. Rng ca bn B. Rng nanh E. Rng ca gia C. Cc rng ca trn TI LIU C THM 1. Hong T Hng (2002), Gii Phu Rng, NXB Y Hc TP.HCM. 2. Nguyn Toi (2003), Gio Trnh Nha Khoa Hnh Thi, Khoa RHM Trng H Y Hu

Chng 2

S MC RNG V D PHNG LCH LC RNG

Mc tiu 1. Trnh by c s hnh thnh v pht trin rng, phn bit c s khc bit v cu to m hc v hnh thi gia rng sa v rng vnh vin 2. Nu c tui mc v thay rng sa, tui mc rng vnh vin, chn on c cc bin chng mc rng v s lch lc rng 3. Gii thch v t vn c cho ngi bnh v gia nh cch d phng lch lc rng.

1. CC GIAI ON PHT TRIN RNG

Giai on phi ca h rng sa bt u vo tun l th 6 n th 8 trong bo thai v ko di n khong thng th 6 sau khi sinh. Giai on phi ca rng vnh vin bt u t thng th 3 n thng th 5 v ko di n thng th 9 sau khi sinh, ring mm rng khn n 4 tui. Khng c mt c quan no khc trong c th ngi li cn mt thi gian di nh th t c hnh th sau cng nh h rng. 1.1. V phng din hnh th Rng tri qua cc giai on pht trin sau y: 1.1.1. L rng Th hin bi giai on khi u. 1.1.2. Giai on mm L s dy ln ca l rng, th hin s tng sinh v bit ha v phng din hnh th. 1.1.3. Giai on hnh nn Th hin bi s tng sinh, bit ha v phng din m hc v hnh th. Giai on ny mm rng c t chc gm: - Lp thng b men bn trong v lp thng b men bn ngoi - Lp t bo hnh sao (trung tm ca c quan to men) - Nh rng c ngun gc t trung m (c quan to ng v ty) - Bao mm rng c ngun gc t trung m 1.1.4. Giai on hnh chung Th hin bng s i su vo bn trong lp trung m ca t bo thng b men. giai on ny xut hin lp t bo trung gian ca c quan to men v nhng mm rng vnh vin cng xut hin t l rng tin pht hay cn gi l rng ca rng sa (rng ca, rng nanh, rng tin ci vnh vin). 1.1.5. Giai on hnh chung tin trin Pht ha ng ni men ng v b tn ca c quan to men to ra bao thng b chn rng Hertwig. 1.1.6. Giai on bao thng b chn rng Lp ng chn rng u tin lng ng v bao thng b chn rng b mt s lin tc. Nhng t bo thng b cn st gi l t bo thng b Malassez. 1.2. V phng din m sinh hc T khi hnh thnh cho n khi mt i, rng tri qua cc giai on pht trin sau y:

1.2.1. Giai on khi u Giai on ny xy ra trong mt thi gian ngn: - L rng hnh thnh vo tun l th 6 trong bo thai - Hnh thnh l rng tin pht cho h rng sa - L rng tin pht hnh thnh 10 im mi hm tng tng ng vi v tr cc mm rng sa sau ny. Mm rng bao gm: C quan to men (ngun gc thng b nim mc ming); Nh rng (trung m); Bao mm rng (trung m). Cc xo trn trong giai on ny c th a n s thiu rng hoc tha rng (vd: msiodent). 1.2.2. Giai on tng sinh C s tham gia ng k s lng t bo v kt qu ca giai on ny l hnh thnh c quan to men. Cc xo trn trong giai on ny a n cc bt thng v kch thc, t l, s lng v rng sinh i. 1.2.3. Giai on bit ha t bo v phng din m hc Cui giai on hnh chung, lp thng b men bn trong ca c quan to men phn mt nhai, lp t bo ny trng thnh, hnh thnh to men bo. Cc t bo ca nh rng phn ha to thnh to ng bo. Ranh gii gia to men bo v to ng bo pht ha nn ng ni men ng. S xo trn trong giai on ny a n cc bt thng ca men v ng: v d: khng hnh thnh men hoc hnh thnh men t, hoc men c th tch dn ra khi ng ni men ng (sinh men bt ton. Hoc to ra s sinh ng bt ton. lm sng kh phn bit gia sinh men bt ton v sinh ng bt thng m ch yu da vo tia X: Trong sinh men bt ton, bung ty v ng ty chn rng c hnh dng bnh thng, trong sinh ng bt ton, bung ty v ng ty chn rng bt kn, chn rng ngn v u chp chn rng khng nhn. 1.2.4. Giai on bit ha hnh th L s sp xp cc t bo to nn hnh dng v kch thc ca thn v chn rng. Giai on bit ha v phng din m hc v hnh th xy ra cng lc. Bao t bo thng b Hertwig hnh thnh bt u t ch lp thng b men bn ngoi v bn trong gp nhau v l kt qu ca hot ng phn chia t bo vng c rng , bao ny ln su vo lp trung m bn di l mt mng gm 2 lp t bo hnh ng xc nh hnh dng chn rng. Trong trng hp rng mt chn, bao ny vn gi dng hnh ng, trong trng hp rng nhiu chn, bao ny b phn chia thnh 2 hoc nhiu ng, ty thuc s chn c to nn. Xo trn trong giai on ny a n bt thng v hnh dng v kch thc (th d, rng ca bn c hnh ht go). 1.2.5. Giai on lng ng cht cn bn Sau khi bit ha, to ng bo bt u tit ra cht tin ng. S pht trin ca cht tin ng nh hng n cc t bo trng thnh ca lp thng b men bn trong, kch thch cc t bo pht trin to thnh to men bo vo to men bo bt u lng ng cht cn bn. S lng ng cht men v ng rng bt u xy ra cc tui khc nhau, nhng nhn chung xy ra theo mt trnh t tng i kh r rng v theo tng nhm: - Nhm 1: trc khi sinh, cc rng sa, t thng th 4 n thng th 6 trong bo thai. - Nhm 2: Khi sinh ra n 5 thng tui, gm rng ci vnh vin th nht v cc rng pha trc. - Nhm 3: t 1 tui ri n 3 tui, gm rng ci vnh vin th 2 v 2 rng ci nh. - Nhm 4: t 7 n 10 tui, gm rng ci vnh vin th 3. Mi khim khuyt giai on ny c xp loi vo s khim khuyt v s lng ca men v ng nh thiu sn men, ng v men gc rng.

2. S KHC NHAU V HNH TH RNG SA V RNG VNH VIN

2.1. Thn rng - Thn rng sa thp hn thn rng vnh vin. - Mt nhai rng sa thu hp nhiu hn rng vnh vin. - C rng sa tht li nhiu v thu hp hn rng vnh vin. - Lp men v ng rng sa mng hn rng vnh vin. 2.2. Ty rng - Nu so snh theo t l vi kch thc thn rng th ty rng sa ln hn. - Sng ty rng sa nm gn ng ni men ng hn rng vnh vin. - V phng din m hc, c rt t s khc bit gia m ty rng sa v rng vnh vin. 2.3. Chn rng - Chn cc rng trc sa di v mnh hn khi so theo t l vi kch thc thn rng. - Chn rng ci sa tch nhau ra gn c rng v cng xa nhau khi i v pha chp chn rng, to ch cho mm rng vnh vin bn di. 2.4. Mu sc Rng sa c mu trng c trong khi rng vnh vin c mu trng ng.

3. S MC RNG
- S mc rng gp phn quan trng trong vic hnh thnh khun mt, gip hon thin s pht m v chc nng nhai - Cc mm rng c hnh thnh t trong xng hm, ln lt di chuyn v mt phn that ra khi cung hm, chnh l phn thn rng nhn thy trong xoang ming. - S mc rng bt u t khi thn rng c hnh thnh v tip din trong sut i ca rng. - Rng mc ln c, mt phn do chn rng cu to di ra, mt phn do s tng trng ca xng hm. khi chn rng cu to hon tt, rng vn tip tc mc ln c, nh vo s bi p lin tc cht cement chp chn rng. - Mi rng c lch thi gian mc v v tr nht nh trn cung hm, nh vy cc rng hm trn v di sp xp th t v n khp vi nhau. - Chn rng c cu to dn dn v hon tt sau 3 nm k t thi im rng mc (hin tng ng chp). Tui ng chp = tui mc rng + 3 V d: Rng s 6 mc lc 6 tui nn tui ng chp rng 6 l: 6 + 3 = 9 tui. - C hai thi k mc rng: + Thi k mc rng sa + Thi k mc rng vnh vin 3.1. Thi k mc rng sa 3.1.1 V tr v tm quan trng ca rng sa - Rng sa l b rng tn ti giai on quan trng nht ca s tng trng v pht trin tr em. Rng sa c hnh thnh t tun th 7 n tun th 10 ca bo thai, c lng ng cht men v ng (s khong ha) t thng 4 n thng th 6 sau khi sinh . - Rng sa mc vo trong xoang ming khong thng th 6 sau khi sinh. n 2 hoc 3 tui, tr em c b rng sa gm 20 rng (10 rng hm trn v 10 rng hm di). - Ngoi chc nng n nhai, pht m, rng sa ng vai tr quan trng trong vic pht trin ca xng hm v gi ng v tr cho rng vnh vin mc ln sau ny.

- Chn rng sa tiu dn khi i n tui thay, rng vnh vin thay th mc dn ln th vo v tr rng sa. - Tr em t 6-11 tui hin din c rng sa v rng vnh vin trn cung hm, gi l rng hn hp (denture mixte). 3.1.2. Tui mc v thay rng sa: rng hm di thng mc v thay sm hn rng hm trn
Bng 2.1: Tui mc v thay rng sa

Tn Rng Hm di - Rng ca gia - Rng ca bn - Rng hm (ci) sa 1 - Rng nanh - Rng hm (ci) sa 2 Hm trn - Rng ca gia - Rng ca bn - Rng hm (ci) sa 1 - Rng nanh - Rng hm (ci) sa 2 3.2. Thi k mc rng vnh vin 3.2.1. Tui mc rng vnh vin

Tui Mc 6 thng 7 thng 12 thng 16 thng 24 thng 7 thng 9 thng 14 thng 18 thng 24 thng

Tui Thay 6 - 7 tui 7 - 8 tui 9 10 tui 10 11 tui 11 tui 7 tui 8 tui 11 - 12 tui 11 - 12 tui 12 tui

Bng 2.2: Tui mc rng vnh vin

Tn Rng - Rng ca gia - Rng ca bn - Rng hm (ci) nh 1 - Rng nanh - Rng hm (ci) nh 2 - Rng hm (ci) ln 1 - Rng hm (ci) ln 2 - Rng hm (ci) ln 3 (Rng khn)

Hm di 6-7 tui 7-8 tui 9-10 tui 10-11 tui 11-12 tui 6-7 tui 11-13 tui 17-21 tui

Hm trn 7 tui 8 tui 9-10 tui 11 tui 12 tui 6-7 tui 12-13 tui 17-21 tui

3.2.2. c im ca rng vnh vin - Mm rng vnh vin, mt s c hnh thnh trong thi k bo thai, t thng th 3 n thng th 5, s cn li hnh thnh sau khi sinh n thng th 9. Ring mm rng khn lc 4 tui - Rng vnh vin c lng ng cht men, ng (s khang ha) bt u t lc sinh ra n 6 - 7 tui. Ring mm rng khn lc 10 tui - Rng vnh vin bt u mc thay th dn rng sa khi tr c 6 tui. - Khi tr 12 - 13 tui, tt c rng sa s c thay th bng rng vnh vin - Lc 17 - 21 tui c b rng vnh vin gm 32 rng.

10

3.3. Cc yu t nh hng n s mc rng - Chiu cao v cn nng Tr cao v mp, rng mc sm hn tr thp v gy. - Gii tnh N mc sm hn nam. - Kch thc xng hm Hm rng, rng mc sm v tha, hm hp,rng mc chm v chen chc - Rng sa Rng sa rng sm hoc chm s lm chm mc rng vnh vin. - Dinh dng Dinh dng km s lm rng mc chm (bnh ci xng) - Vim nhim xng hm Xng hm b vim nhim trong thi k mc rng s lm rng mc sm - Yu t di truyn 3.4. Bin chng mc rng - Khi mc rng tr em thng c nhng biu hin sau: st, ho, i chy, chy nc bt, quy khc, nga li rng. X tr: dng h st, an thn, v sinh rng ming tt. - i vi rng khn (rng hm / ci ln 3) khi mc thng gy nhiu bin chng, thng biu hin bng tnh trng vim quanh thn rng. X tr: khng sinh, gim au, chuyn chuyn khoa.

4. HNH THI LM SNG LCH LC RNG, IU TR, D PHNG

4.1. S chen chc rng ca Du hiu chen chc u tin h rng hn hp thng trng vi s mc rng vnh vin. Thiu chiu di cung rng c th biu hin bng nhiu cch t xoay rng ca v lch lc nh n chen chc rng ca trm trng. iu quan trng l phn tch khong trng v xc nh mc thiu khong. 4.1.1. Chen chc nh - S chen chc nh c coi l bnh thng bnh nhn khng c mt chiu di cung rng. Khng cn iu tr, ch theo di. - Nu rng ca bn mc nging v pha li, c th iu tr n gin bng cch mi mt gn rng nanh sa bng a giy nhm vi tay khoan thng hoc bng mi khoan siu tc vi mi khoan chp nhn. 4.1.2. Chen chc trung bnh Chiu di cung rng thiu mc di 5mm. Trng hp ny thng do mt khong sau nh rng hoc mt sm rng sa, cn c chuyn cc nh iu tr chuyn mn vi nhng kh c c nh hoc tho lp di chuyn rng, ly li khong trng mt. 4.1.3. Chen chc trm trng Mt chiu di cung rng trn 5mm c coi l trm trng, cn c iu tr c bit bng cch ni rng cung rng hoc nh chn lc mt s rng vnh vin.

11

4.2. Sai lch rng theo chiu trc sau 4.2.1. Cn cho rng trc L tnh trng cc rng ca trn nm pha trong (sau) cc rng ca di khi ngm hm, nhng bnh nhn ny mi trn b lp (mm), nguyn nhn c th do rng hoc xng. Nu nguyn nhn do xng th cn c kin ca chuyn vin, nu do rng v nhng trng hp n gin (cn cho mt vi rng) c th can thip c bng nhng kh c tho lp n gin nh mt phng nghing hoc hm nha vi l xo ngn tay... 4.2.2. Rng ca a ra trc L tnh trng cc rng ca trn hoc cc rng ca di a ra pha trc m ngi ta c th gi nm na l "h". Nguyn nhn c th do rng hoc xng, nu do xng cn tham kho chuyn vin, nu do rng c th iu tr bng cch y rng nghing v pha sau bng nhng kh c tho lp c cung mi v nhng cung b tr hnh ch U. 4.3. Sai lch rng theo chiu ng Sai lch rng theo chiu ng thng biu hin giai on rng hn hp l cn h v cn su. 4.3.1. Cn h Thng gp nht l do thi quen mt ngn tay lm cn tr s mc rng y ca cc rng trc. Vic iu tr c bn l iu tr thi quen mt ngn tay giai on rng sa bng cch lm cc kh c ngn cn thi quen mt ngn tay nh tm chn khu ci, tm cn ny ngoi cng dng iu tr tt mt tay cn ngn khng cho li chn vo gia cung rng trn v di, hoc nhn ro cn ngn tay 4.3.2. Cn su L tnh trng cc rng trc mc qu mc hoc rng sau mc khng y . Bnh thng t th ngh, b cn rng ca trn cch ng mi trn khong 2mm, nu khong cch ny trn 2mm cn quan tm n s mc qa mc ca rng trc hm trn. Vic iu tr l phc tp cn c s can thip ca cc chuyn gia chnh hnh.

CU HI T LNG GI
Cu 1: S mc rng c bt u khi: A. Tr 6 thng B. Tr 6 tui C. Khi rng cu to hon tt xong D. Khi thn rng c hnh thnh xong E. Khi chn rng c cu to gn xong Cu 2: Tui ng chp chn rng bng tui mc rng cng vi: A. 2 B. 3 C. 4 D. 5 E. 6 Cu 3: Yu t chnh gip rng tip tc mc ln sau khi chn rng cu to hon tt: A. S tng trng ca xng hm B. S pht trin ca thn rng C. S bi p lin tc cht cment chp chn rng D. Chn rng tip tc cu to di ra E. Rng iu chnh theo chiu gn-xa

12

Cu 4: Vai tr quan trng khc ca rng sa ngoi chc nng n nhai, pht m: A. Cu to mm rng vnh vin B. Bo v mm rng vnh vin C. Gi v tr cho mm rng vnh vin D. Gip s khong ho mm rng vnh vin E. Cn tr s mc ln ca rng vnh vin Cu 5: Mm rng sa c hnh thnh lc: A. Tun th 3- 5 thai k B. Thng th 3-5 thai k C. Tun th 7-10 thai k D. Thng th 7-10 thai k E. Sau khi sinh Cu 6: Mm rng sa c khong ho lc: A. Thng th 7-10 thai k B. Tun th 7-10 thai k C. Thng th 4-6 thai k D. Tun th 4-6 Thai k E. Sau khi sinh Cu 7: Rng hm sa th nht hm di thng c thay th bng rng ci nh vnh vin lc: A. 7-8 tui B. 8 tui C. 9-10 tui D. 13 tui E. 14 tui Cu 8: Mm rng khn c hnh thnh vo lc: A. Thng th 3- 5 thai k B. Thng th 9 sau sinh C. Lc 4 tui D. Lc 10 tui E. Lc 18 tui Cu 9: Rng hm (ci) ln th nht mc vo lc: A. 4-5 tui B. 6-7 tui C. 8-9 tui D. 10-11 tui E. 11-12 tui Cu 10: Khi rng hm sa th hai phn hm di tri n tui thay, rng vnh vin mc ln thay th n l: A. Rng 34 B. Rng 44 C. Rng 35 D. Rng 45 E. Rng hm vnh vin th hai

TI LIU C THM
1. Hong T Hng (2001), M Phi Rng Ming, NXB Y Hc TP.HCM. 2. Trn Thanh Phc (2003), Gio Trnh Chnh Hnh Rng Ming, B mn RHM Trng H Y Hu

13

Chng 3

BNH SU RNG
Mc tiu hc tp 1. Trnh by c nguyn nhn ch yu gy bnh v yu t nguy c. 2. Gii thch c c ch gy bnh. 3. Chn on c cc th bnh v lit k cc bin chng ca bnh su rng. 4. Nu c nguyn tc iu tr v cc bin php d phng.

1. NH NGHA
Su rng l mt bnh t chc cng ca rng (men, ng v cement), c trng bi s kh khong lm tiu dn cc cht v c, hu c men rng, ng rng to thnh l su v khng hon nguyn c. C nhiu nh ngha v bnh su rng, da trn nhng nghin cu v nhn xt khc nhau v nguyn nhn cng nh tin trnh ca bnh, bnh su rng c th c nh ngha nh sau: - Bnh su rng l mt qu trnh ng, din ra trong mng bm vi khun dnh trn mt rng, a n mt cn bng gia m rng vi cht dch chung quanh v theo thi gian, hu qu l s mt khong ca m rng (Fejerkov v Thylstrup). - L bnh nhim trng ca m rng biu hin c trng bi cc giai on mt v ti khong xen k nhau (Silverston).

2. DCH T HC SU RNG
Su rng l mt bnh ph bin nc ta cng nh cc nc trn th gii, bnh mc rt sm v gp mi la tui, mi gii, mi dn tc, mi vng a l khc nhau, mi tng lp x hi, trnh vn ha. Su rng l mt bnh mang tnh cht x hi v c xu hng tng cng vi s pht trin ca nn kinh t. Nm 1969, ngn hng d kin sc kho rng ming th gii ca T chc sc kho th gii (WHO / OMS) c thnh lp, cho thy nh hng ca bnh su rng trn th gii c hai khuynh hng tri ngc nhau. Ti cc nc pht trin, su rng gim r rt t mc cao xung trung bnh hay thp, trong khi cc nc ang pht trin su rng c khuynh hng tng t thp n trung bnh hay cao. 2.1. T l bnh v ch s SMT o lng mc bnh su rng, ngi ta dng t l % v ch s SMT, trong S l rng su, M l rng mt do su v T l rng trm, SMT l ch s ch p dng cho rng vnh vin v khng hon nguyn c ngha l ch s ny mt ngi ch c tng ch khng c gim. SMT tng ngi c th ghi t 0 n 32, i vi nghin cu dch t hc, SMT ca cng ng l tng s SMT ca tng c th chia cho s c th ca cng ng. i vi rng sa, khi p dng ch s ny s c k hiu bng ch thng smt, trong s l rng su, m l rng nh v t l rng trm. Trn th gii, so snh quc t v gim st xu hng ca bnh su rng, ngi ta tnh ch s SMT la tui 12 (s rng su mt trm trung bnh mt ngi) theo cc mc : - Rt thp : 0,0 - 1,1 Th d: Trung Quc - Thp : 1,2 - 2,6 Cam pu chia, M, Nht, c

14

- Trung bnh : 2,7 - 4,4 B, Canada, Thu in - Cao : 4,6 - 6,6 Thi Lan, Na Uy - Rt cao : > 6,6 Chi L Vit nam theo iu tra c bn sc khe rng ming ca ton quc nm 1990, t l bnh su rng cc la tui v cc vng a l nh sau:
Bng 3.1: T l bnh su rng theo tui v vng a l

La tui 12 15 35-44

T l chung (1) 57% 60% 72%

H Ni (1) 36% 44% 76%

Hu (2)

TP HCM (1) 83,9% 96% 92%

Cao Bng (1)

Lt Lm ng (3) 82,25%

41,2% 43,7% 64,2%

60% 62% 68%

Sau 10 nm, qua iu tra sc kho rng ming ton quc nm 2000 (S liu ca Trn vn Trng - Tp ch Y Hc Vit Nam s 10 / 2001), t l su rng trn ton quc cc la tui nh sau: - Rng sa: 6 tui 83,7% , ch s smt 6,15. - Rng vnh vin: + 12 tui 56,6%, SMT 1,87 + 15 tui 67,6% , SMT 2,16 Nhn chung trn th gii, nhng nc ang pht trin t l su rng cn cao, nhng nc pht trin th t l su rng gim r rt nh cc chng trnh chm sc sc kho rng ming cng ng, s ci thin v cc dch v nha khoa phng nga. 2.2. c im dch t hc ca bnh su rng - T l su rng gia tng theo tui c h rng sa ln rng vnh vin. S phn b su rng cng khc nhau gia cc rng v cc mt rng, su rng gim dn t rng ci ln di, n rng ci ln trn, rng ci nh, rng ca trn, rng ca di. T mt nhai n mt tip cn, mt ngoi, mt trong. - Su rng chu nh hng ca mi trng gia nh v trng hc. - Trnh vn ho cng cao th tnh trng sc kho rng ming c nng cao, c bit l kin thc ca ngi m. - Nn kinh t - x hi cng pht trin t l bnh cng gia tng. Ngoi ra, ph tn cha rng rt ln, th d M 9 t USD / nm, Php 8 triu Franc / nm, Vit Nam cha tnh c (V Th Quang - Phng bnh su rng bng Fluor - Nh xut bn Y hc), ng thi mt rt nhiu gi cng lao ng. Mt khc, bnh cn dn n nhiu bin chng nh hng n sc khe chung, thm m v d ti pht sau khi iu tr.

3. NGUYN NHN
Su rng gn nh l mt bnh mc phi do iu kin mi trng, v vy cc yu t ti ch l nguyn nhn c bn v ch yu ca bnh su rng cn nguyn nhn tng qut ch l nhng yu t nguy c. 3.1. Nguyn nhn ti ch Cn ti thiu 4 yu t chnh ng thi tng tc vi nhau to nn sang thng su. l: rng nhy cm, vi khun (mng bm), cht ng v thi gian (Keyes, 1969).

15

3.1.1. Tnh nhy cm ca rng iu hin nhin l phi c s hin din ca rng trong mi trng ming, sau mt s yu t lm tng tnh nhy cm ca rng i vi s khi pht su rng mi c th nh: - V tr ca rng trn cung hm + Rng mc lch lc, xoay d b su hn rng mc thng hng. + Nhm rng hm b su nhiu hn nhm rng ca. - c im hnh thi hc + Mt nhai b su nhiu nht v c nhiu rnh lm. + Mt bn cng d b su v men rng vng c mng, git thc n. + Mt trong, ngoi t b su hn v trn lng. - Thnh phn cu to ca rng Rng b khim khuyt trong cu to nh thiu sn men, ng rt d b su. - Mn rng Rng b mn phn men cng d b su hn (mn rng c th do chi rng sai phng php, mc rng gi, nghin rng, n nhai lu ngy...). - Tui rng Rng mi mc km cng, d b tc dng ca acid, vi thi gian men rng c ti khong ho lm chng khng hn vi acid. 3.1.2. Vi khun y l nguyn nhn cn thit khi u cho bnh su rng, tuy khng c loi vi khun c bit gy su rng, nhng khng phi tt c vi khun trong ming u gy ra su rng. Vi khun bao gm lng mng bm, cc cht bin dng v c t ca n. Ty theo vai tr gy su rng, cc vi khun c chia lm hai nhm: - Vi khun to acid Cc loi vi khun ny ln men carbohydrate to ra acid, lm pH gim xung < 5, s gim pH lin tc c th a n s kh khong trn b mt rng, lm mt vi cc m cng ca rng, qu trnh su rng bt u xy ra, nhm ny gm: + Lactobacillus acidophillus: hin din vi s lng t, nhng li to ra acid c pH thp rt nhanh trong mi trng. + Streptococcus mutans: y l tc nhn ch yu gy ra s thnh lp mng bm, dnh trn b mt rng v nu c s hin din cng lc hai yu t cht ng, thi gian th s c iu kin thun li khi pht sang thng su; sau L. acidophillus lm sang thng tin trin xung bn di b mt. + Actinomyces: cng c th gy su rng. - Vi khun gii protein Lm tiu hy cht cn bn hu c sau khi mt vi. 3.1.3. Thc phm L nhng thc n cn thit m c th hp thu vo sng v hot ng. Tuy nhin, thc phm cng l mt yu t lin quan n bnh su rng, v cng l cht dinh dng ca vi khun. Ty theo loi thc phm, tnh cht ca thc phm v ch s dng n, m c th su rng hoc khng. - Carbohydrat Cc cht bt, ng l loi thc phm gy su rng nhiu nht. Trong ng l loi thc phm ch yu gy su rng v lm gia tng su rng, c bit l loi ng sucrose, y l

16

cht a thch ca vi khun gy su rng, n chuyn ho thnh acid v chnh s sinh acid ny lm mt khong men. iu quan trng l kh nng gy su rng khng phi do s lng ng, m do s ln s dng v thi gian ng bm dnh trn rng. ng trong tri cy, rau (xilitol, sorbitol) t gy su rng hn ng trong bnh ko. Tinh bt khng phi l nguyn nhn ng k, v trong nc bt c enzyme amylase bin tinh bt thnh ng rt chm. - Protid Cc loi Protid nguyn thy t gy su rng, ngc li nhng loi protid c ch bin lm tng su rng do tnh cht bm dnh ca n. - Lipid . Cc cht bo khng gy su rng. Nhng thc phm c tnh cht x t gy su rng, trong lc nhng thc phm mm do, dnh vo rng th d gy su rng hn. Ch n y , ng ba, khng n vt s gim c su rng. 3.1.4. Thi gian Vi khun gy su rng sau khi nhim vo mi trng ming, t n s khng gy su rng c m cn phi c cht ng gip cho s chuyn ho ca vi khun, tuy nhin su rng khng ph thuc vo s lng, s ln s dng ng m ph thuc vo thi gian ng v mng bm vi khun tn ti trn b mt rng, thi gian tn ti cng lu th vi khun chuyn ho ng thnh acid cng nhiu v acid tn cng gn nh thng xuyn trn b mt rng lm mt khong men. Tuy nhin, qu trnh mt khong c th phc hi hoc gim mc nh cc thnh phn khc nhau trong nc bt, tc tit. 3.1.5. Nc bt L mi trng hot ng ca cc vi khun trong ming, nc bt tit cng nhiu cng gim su rng (trung bnh mt ngy nc bt tit ra 1.500cc, khi ng lng nc bt tit ra gim ng thi vic chi ra vi khun v cht carbohydrat mc ti thiu, v vy su rng tng trong gi ngh). Ngoi ra tnh cht nc bt lng hay qunh cng nh hng n bnh su rng, nc bt cng qunh th su rng cng cao. Nc bt gi vai tr: - Trung ha acid: trn b mt men rng lun lun xy ra hai hin tng tri ngc nhau: s to acid bi vi khun v s trung ha acid bi nc bt. - St khun: ngn cn s pht trin ca vi sinh vt nh cc cht lysozyme, lactoperosidase, lactofferrin cha trong nc bt. - Chi ra: lm sch rng thng xuyn, vi s phi hp c ng ca mi, m v li v.v..., lm chm qu trnh hnh thnh mng bm. - Ti khong ha: nh thnh phn calci, phosphate trong nc bt c th tch t men trong giai on sm ca sang thng su rng, kh nng ny s tng ln nu c s hin din ca fluor. 3.2. Nguyn nhn tng qut y l nhng yu t nguy c nh hng n su rng 3.2.1. Ni ging (chng tc, dn tc) Theo quan nim ngy xa cho rng c mt vi chng tc c sc khng tt vi su rng, nhng ngy nay quan nim khng cn gi tr m su rng tu thuc nhiu vo mi trng sng v vng a l hn l chng tc. Mt s ngi thuc chng tc t su rng tr nn nhy cm vi su rng khi di tr n ni c nn kinh t pht trin, thi quen dinh dng v nn vn ho khc ni h sng trc . Th d dn sng Bc cc t b su rng hn dn sng n

17

i, nhit i (chu u, chu ) v chng lnh h thng dng thc n loi lipid hn, nhng khi di tr n chu u, tnh trng su rng ca h cng thay i theo ni . 3.2.2. Di truyn Hin nay vn cha c chng minh r rng. Tuy nhin, ngi ta nhn thy tr em t b su rng thng cha m c rng tt hoc ngc li v ngi ta cho rng su rng c nh hng rt r vi mi trng gia nh, do thi quen ca tr c hnh thnh rt sm v nh hng ch yu t gia nh. c bit trong vn gio dc, dinh dng v chm sc con ca ngi m. 3.2.3. Phi tnh Thng thng nam t su rng hn n, c th do n n vt nhiu hn, mt khc n cn chc nng thai nghn, cho con b, ri lon ni tit...v n mc rng sm hn nam. 3.2.4. Tui Ngi ta nhn thy bnh su rng khng pht trin u n trong sut i, thng la tui t 4-8 b su nhiu, giai on ny nhng rng sa b ph hy rt nhanh v nhiu. T 11 - 19 tui, cc rng vnh vin bt u b su nhiu. 3.2.5. Ngh nghip Tuy cha c chng minh r rng ch nhn thy cng nhn lm vic cc nh my ng, x nghip bnh ko d b su rng. 3.2.6. Yu t ni tit Khi tuyn yn, tuyn cn gip hot ng km s nh hng n s thnh lp men, ng gy nn tnh trng rng b thiu sn men, men ng bt ton hoc ri lon ni tit tui dy th, thai nghn... 3.2.7. Bnh ton thn Nhng bnh thi gian ko di nh si, thng hn... dn n v sinh rng ming km a n su rng, hoc bnh nhn b chng kh ming (xerostomia), x tr tuyn nc bt, tiu ng..., t l su rng tng. 3.2.8. Kinh t - vn ho - x hi nh hng gin tip qua i sng, sinh hot v nhn thc ca con ngi, vn ho cng cao th nhn thc ca con ngi c nng cao v mi mt. Kinh t pht trin mi nhu cu cng gia tng, c bit l gia tng mc tiu th ng s nh hng n t l bnh su rng. X hi cng pht trin, cc dch v chm sc y t, cc chng trnh phng bnh c quan tm nhiu hn...

4. SINH BNH HC
C rt nhiu thuyt gii thch c ch gy bnh, trong thuyt sinh acid (thuyt ha hc vi khun) ca Miller (1882) c nhiu ngi chp nhn nht. Theo Miller, vi khun tc ng ln bt, ng sinh ra acid, lm pH trong mi trng ming gim xung < 5 trong vng 1 - 3 pht, s gim pH lin tc a n s kh khong ca rng, qu trnh su rng bt u. T thuyt ca Miller, Keyes (1962) tm tt li thnh mt s gm ba vng trn biu th cho vi khun, rng (men rng), thc n (bt, ng), sau c b sung thm yu t thi gian. Phi c 4 yu t tc ng h tng, mi c su rng. n 1975, ngi ta nhn thy su rng khng phi ch c ng v vi khun S. mutans, m cn chu nhiu yu t khc chi phi, nn White thay vng trn cht bt ng bng t cht nn (substrate), bao hm vai tr bo v rng v trung ha acid ca nc bt, v sinh rng ming, kem nh rng c fluor. c bit l pH ca nc bt v dng chy nc bt quanh rng.

18

rng

vi khun * VK R

bt, ng

thi gian

B,

Su rng S 3.1: Keyes

S 3.2: White

5. GII PHU BNH

5.1. i th L su thng thng c hnh cu, phn men b ph hy t hn phn ng (cht khong men > ng), b l su lm chm, y v thnh l su c ng mm. L su c th to hoc nh, nng hoc su.

Lp hoi t Lp nhim trng Lp b nh hng Lp x ha

i th

Vi th (su ng)
Hnh 3.1: Gii phu bnh su rng

2. Vi th 5.2. Vi th 5.2.1. Su men Khi men rng b ph hy, di knh hin vi in t thy cc tr men b ct thnh tng mnh nh, sau n nhng tr men b tch rng ri n men rng bnh thng. 5.2.2. Su ng Khi ph hy qua phn ng, di knh hin vi thy l su c bn vng: - Vng hoi t vng ny cc tr men b h hi, c cc mnh vn ng rng, vi khun trong ming, lp ny thng b che ph bi mt lp thc n.

19

- Vng nhim trng ng ng b xm ln bi vi khun, trong lng ng ng v chung quanh ng ng u c hin tng mt cht khong. M b ph hy khng c kh nng hi phc. - Vng b nh hng Gia lp ny, lng ng ng b xm nhp bi mt s vi khun, trong lng ng v chung quanh ng ng hi b mt cht khong. - Vng x ha Lng ng ng b bt li bi nhng phn t cht khong, y l bc tng ngn cn s xm nhp ca vi khun v ch c rng cn sng.

6. HNH TH LM SNG V TRIU CHNG

6.1. Su men y l hnh th u tin ca bnh su rng, khc vi cc m khc, men rng khng c t bo mch mu, thn kinh, nn triu chng ch quan cha c. Triu chng khch quan: - Tn thng thng thy h v rnh mt nhai, hoc chung quanh ra ming trm c. - Men rng i mu trng c hoc vng nu. - Dng thm trm khm thy men rng lm chm khng cn trn lng v mc kt. 6.2. Su ng L giai on tip theo ca su men khng iu tr hoc su ngay t u nu l ng (thiu men vng c rng, mn ngt cement vng chn rng). Ng rng l m c thn kinh v phn ko di ca nguyn bo to ng trong cc ng ng, nn d mi chm cng c cm gic au vi nhng kch thch vt l, ha hc, c hc. 6.2.1. Triu chng chc nng - au do kch thch (nng, lnh, chua, ngt, thc n lt vo, mi xoang...). - au chm dt ngay sau khi ht kch thch v t li rng nguyn nhn khng lan ta. 6.2.2. Triu chng thc th - Men, ng rng chung quanh l su i mu trng c, vng hoc hi nu. - Khm bng thm trm: b l su lm chm, thnh v y l su c lp ng mm, no quanh l su bnh nhn c cm gic au. - G rng khng au. 6.3. Su c rng: su xi mng (cement) Thng gp ngi gi do nu b co li, nht l 1/3 c, vng ranh gii men-xi mng. V lp xi mng mng nn su xi mng d bin thnh su ng.

7. CHN ON
7.1. Chn on xc nh Da vo triu chng lm sng: au do kch thch, men rng i mu, y l su c lp ng mm... 7.2. Chn on phn bit Trn rng c th c cc tn thng khng do su cn phn bit vi tn thng su nh: 7.2.1. Thiu sn men - C khi rng mi mc. - Thng i xng hoc trn cc rng mc cng thi k. - y cng, khng c lp ng mm.

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7.2.2. Mn ngt c rng (lm hnh chm) - vng c rng, mt ngoi cc rng 3, 4, 5 (do chi rng sai phng php), hoc mt trong v mt ngoi ca nhng rng mang mc hm gi tho lp. - y cng v trn lng. 7.2.3. Sn rng tr em Ch c h rng sa v thng xy ra tr trc tui n trng, gp trn cc rng ca, rng nanh hm trn. Tn thng lan theo chiu rng, y cng, khng au d mt n na thn rng.

8. IU TR
8.1. Su men Trc y, thng ph sch cc rnh mt nhai trm d phng. Ngy nay, nh nhng hiu bit mi, men rng c kh nng ti khong ha, nn su men khng cn iu tr ch cn gi gn v sinh rng ming v tng cng s dng Fluor. Tuy nhin, i vi tr c nguy c su rng cao nh v sinh rng ming km, thng xuyn n cht ng (bnh ko, sa, nc ngt) th cn phi trm d phng bng composite, glass ionomer cement (GIC). 8.2. Su ng Nguyn tc trong iu tr su ng l lm sch l su bng cch no sch ng mm, st khun v trm kn vi vt liu thch hp (Eugenate, Amalgame, Composite, Glass Ionomer Cement), nhm lm mt cm gic au cho bnh nhn. Ngy nay vi vt liu hin i c th trm rng m khng cn my khoan rng, c gi l k thut trm rng khng sang chn (A.R.T: Atraumatic Restorative Treatment), y l mt phng php trm rng vi dng c bng tay v G.I.C, k thut rt thch hp vi tr em cng nh nhng ni khng c my mc, bc s chuyn khoa, in...

9. TIN TRIN V BIN CHNG

T su ng khng iu tr, bnh su rng s tin trin n ty gy vim ty cp, sau ty s b hoi t dn a n vim ty mn ri n ty cht, thi. Nhng cht hoi t ca ty c th thot qua l chp chn rng gy nn nhng bnh l vng quanh chp, vim t chc lin kt, vim xng hm..., hoc t li chn rng to nn u ht, nang chn rng... Ngoi ra, vi khun c th gy nhng bin chng xa nh vim xoang hm, vim ni tm mc (Osler)... Thng thng, bin chng ca su rng khng nguy him, nhng din tin ca bnh s tri qua nhiu t au lm mt n, mt ng, nh hng n sc kho, hc tp v cng vic.

10. D PHNG
Su rng l mt bnh ph bin, t l mc bnh li cao khng ch s lng ngi m c s rng su trung bnh mt ngi. Trong khi trang b v ngi cha c m ph tn iu tr rt ln, nn vic phng bnh cn c quan tm. Tuy nhin vic gi gn sc khe rng ming i hi phi c s hp tc lu di v khng ngng gia nha s v bnh nhn. Ngy nay vic d phng su rng khng phi l kh, da vo nguyn nhn v c ch sinh bnh, chng ta bit rng su rng xy ra cn bn yu t c bn phi hin hu ng thi: - Mt lng ln vi khun sinh su rng. - Mt rng d b su (men rng xu, h rnh...). - ng, bt. - Thi gian tn ti ca ng, mng bm trn rng. Su rng khng xy ra, hoc c phng nga hoc c ngn chn khi mt trong bn yu t trn khng cn. Do vy, bc s nn hng dn bnh nhn cc phng php hu hiu sau y: - Gim s lng vi khun (tc nhn) bng cc bin php v sinh rng ming.

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- Gim mt rng d b su (vt ch) bng cch tng cng s dng Fluor. - Gim s tip xc thng xuyn vi cht bt, ng (mi trng), trnh n vt, hn ch n bnh ko... C th i vi cng ng, ta c cc cp d phng sau : 10.1. Cp 0: khi bnh cha xy ra - Ci to mi trng nc ung c Fluor (i vi vng thiu Fluor, hm lng Fluor trong nc sinh hot < 0,7 ppm), bng cch: + Fluor ha nc cng cng vi nng 1/ triu. + Fluor ha nc trng hc vi nng 4/ triu. - Nng cao i sng kinh t, vn ha nng cao nhn thc v bo m ch dinh dng cho ton dn, cn nht i vi ph n mang thai, cho con b v tr em. 10.2. Cp 1: khi bnh c kh nng xy ra - Trin khai chng trnh nha khoa cng ng, ch yu gio dc phng bnh. - Trin khai chng trnh nha hc ng trn ton quc vi cc ni dung gio dc nha khoa, sc ming vi NaF 0,2 % 1 tun / ln, t chc khm v cha rng ti trng, trm bt cc h rnh. - Hng dn cc bin php v sinh rng ming ch yu l chi rng sch sau khi n v trc khi ng, chi ng phng php. - Kim sot thc phm (gim lng carbohydrate, trnh n vt) - Tng cng s dng Fluor di mi hnh thc: + Chi rng vi kem nh rng c Fluor + Sc ming vi NaF 0,2 % tun / ln. + Gel Fluor bi. + Ung vin Fluor vi liu lng nh sau: 0 - 6 thng : 0,25 mg F / ngy 6 - 18 thng : 0,25 - 0,5 mg F / ngy 18 - 2 nm : 0,25 - 0,75 mg F / ngy Sau 2 tui : 0,5 - 1,0 mg F / ngy - Phc hnh rng mt, chnh hnh rng mc lch lc. 10.3. Cp 2: khi bnh xy ra - iu tr sm su ng. - Khm rng nh k mi nm mt ln pht hin sm cc tn thng. 10.4. Cp 3: khi tin trin n ty - iu tr ty ngay, khng cc bin chng nng xy ra. - Nh nhng rng khng th iu tr bo tn trnh tn ti mt nhim trng./.

CU HI T LNG GI
Cu 1. Ch s SMT la tui 12 ca Vit Nam nm 2000 l 1,87 c nh gi l: A. Rt thp B. Thp C. Trung bnh D. Cao E. Rt cao

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Cu 2. Yu t no sau y lm tng tnh nhy cm ca rng i vi s khi pht su rng: A. Rng nhim tetracyline D. Rng c nhiu cao rng B. Rng mc lu trn cung hm E. Rng d dng C. Rng nhim Fluor Cu 3. Loi vi khun no sau y lm pH gim nhanh trong mi trng ming: A. Streptococcus mutans D. Streptococcus sanguis B. Lactobacillus acidophillus E. Vi khun gii protein C. Actinomyces Cu 4. Thc phm no khng gy su rng: A. Tht ti D. Tht hp B. Du m E. Tri cy C. Tinh bt Cu 5. Nc bt c kh nng ti khang ha sang thng su rng sm nh: A. Lysozyme lactoferine. D. Nc bt tit nhiu B. Lm sch rng thng xuyn E. Nc bt lng C. Ca++ Cu 6. Theo White, yu t no sau y chi phi su rng c bit nht: A. Fluor D. Nc bt B. Vi khun E. Cht nn C. ng Cu 7. Triu chng au trong su ng c c im sau: A. au tng cn B. au ngng khi ht kch thch C. au lin tc D. au ko di t pht sau khi ht kch thch E. au nh mch p Cu 9. Tn thng su men thng thy : A. H rnh mt nhai D. Mt trong rng ci di B. Mt trong rng ca gia E. Mi rng C. Mt ngoi rng ci trn Cu 9. Su ng cn phi iu tr ch yu bng cch: A. V sinh rng ming D. Trm kn l su B. Sc ming vi Fluor E. Che ty. C. Ly ty Cu 10. Bin chng no xy ra sm nht nu khng iu tr su ng: A. Ty cht D. Ty hoi t B. Vim ty mn E. Vim quanh chp C. Vim ty cp

TI LIU C THM
Nguyn Thc Qunh Hoa (2005), Gio Trnh Cha Rng Ni Nha, Khoa RHM Trng H Y Hu

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Chng 4

BNH L TY RNG V VNG QUANH CHP

Mc tiu hc tp 1. Lit k c cc nguyn nhn gy vim ty v bnh vng quanh chp rng 2. Nu c cc triu chng lm sng, nguyn tc iu tr vim ty v bnh vng quanh chp rng.

1. BNH L TU RNG
1.1. i cng Ty rng c cu to bi khi m lin kt non giu mch mu v dy thn kinh. Ty rng nm trong hc ty c bao bc xung quanh bi lp m cng ca rng l ng (ngoi tr l chp chn rng). c im ca mch mu ty rng l mch mu tn cng, vo ra hc ty bi l chp chn rng, nn khi ty b vim th d b xung huyt nn gy au nhc v d b hoi t. Bnh l ty thng thng l bin chng ca su rng, nhng cha c mt s liu chnh xc no ni n t l bnh ty v bnh vng quanh chp. 1.2. Bnh cn 1.2.1. Nguyn nhn gy bnh C th chia lm 3 nhm - Do vi khun: vi khun v sn phm ca vi khun i vo ty qua ng ng (su ng) hoc qua l chp chn rng (bnh nha chu) - Nguyn nhn t to: l do nhng li v iu tr v k thut - Do chn thng: chn thng nh lin tc v chn thng mnh gy gy rng. 1.2.2. ng xm nhp vo ty C th theo 3 ng - Xm nhp trc tip qua ng ng nh trong su rng hay ha cht t ln ng - S khu tr ca vi khun trong mu i n ty rng - Vim ty ngc dng do vim nha chu. 1.3. Hnh th lm sng v triu chng 1.3.1. Ty vim c kh nng hi phc - Triu chng chc nng + au do kch thch nh n ngt, chua, lnh + Thi gian au ngn khong vi giy + Thc cht cn au l au nhi v khu tr + Bnh nhn khng c tin s ca mt cn au trc y.

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- Triu chng thc th + L su nhiu ng mm, no ht ng mm c th thy nh hng ca ty hoc l sng ty gy au nhiu + G v lung lay rng khng au + Th nhit : lnh gy au 1.3.2. Ty vim khng c kh nng phc hi C th l cp, bn cp, kinh nin, c th l mt phn hay ton phn. Trn lm sng vim ty cp c xem nh vim ty c triu chng v vim ty kinh nin c xem nh vim ty khng c triu chng. 1.3.2.1. Vim ty cp - Triu chng chc nng + Cn au t pht ko di thng hay xy ra vo ban m nht l khi bnh nhn nm xung + Cn au c th do kch thch nh s thay i nhit , thc n lt vo l su + Cn au c th nhi hay m , khu tr hay lan ta + au tng cn hay lin tc. - Triu chng thc th + G ngang au nhiu, g dc au nh hoc khng au + Khm thy rng su l ty hay nu xung quanh rng c ti nha chu + Nhit : nng au, lnh gim au + Th in c gi tr nghi ng chn on chnh xc tnh trng Vim ty cp triu chng c th dai dng hay gim bt nu dch tit c dn lu (ly thc n nhi nht trong l su, ra sch...) nu khng iu tr s dn n vim ty kinh nin, hoi t ty. 1.3.2.2. Vim ty kinh nin - Triu chng chc nng: thng khng c hoc ch au thong qua khi c kch thch - Triu chng thc th: ty hnh th bnh ta c: + Vim ty trin dng + Do mt kch thch cng nh lin tc trn m ty giu mch mu, thng gp nhng bnh nhn tr + Bnh nhn khng c triu chng tr mt cn au nh thong qua khi nhai + Khm c mt nm mc gia thn rng dng thm trm chc vo bnh nhn au t ng thi mu chy ra nhiu. + Vi ha ng ty: Do cha rng, iu tr nha chu (co lng gc rng lm t tun hon mu ng ty ph), mn rng do sinh l, mn rng do c hc, chn thng hay mt s yu t khng r nguyn nhn lm cho ty rng b vim. Rng khng c triu chng nhng c th hi i mu Thng nhn bit bi phim tia X (do c s tch t mt s lng ln ng th cp sut dc h thng ng ty)

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+ Ni tiu Ch pht hin trn phim tia X, thy c s lan trn ca m ty vi s ph hy ng rng. Trng hp nng c th thy m hng xuyn qua men 1.3.2.3. Hoi t ty Do ty vim khng hi phc m khng iu tr, hoc xy ra tc khc sau chn thng mnh. Ty hoi t c th bn phn hay tan phn - Triu chng chc nng: khng c - Triu chng thc th: rng b i mu sm hn, khoan m ty c th c mi hi, g khng au, khng c phn ng vi nhit in. 1.4. Chn on 1.4.1. Xc nh Da vo triu chng lm sng 1.4.2. Phn bit - Vim quanh chp cp (rng tri v lung lay g dc au d di) khc vi vim ty cp(rng bnh thng g ngang au) - Su ng (khoan rng c cm gic but), vim quanh chp mn (trn phim c mt vng thu quang chp chn rng) khc vi hoi t ty (chp chn rng bnh thng, khoan rng khng c cm gic but). 1.5. iu tr 1.5.1. Vim ty c kh nng hi phc Phi loi b cc nguyn nhn sau: C l su ln hay ming trm Amalgam qu su gy au, cn no ht phn su hoc ly ht Amalgam trm. Sau trm tm bng Zinc Oxide Eugenol hoc che ty vi Ca(OH)2 v trm tm bng Zinc Oxide Eugenol trong nhiu tun c th lm gim au cho bnh nhn. Sau nhiu tun ht au, rng c th c trm vnh vin. Hin nay theo cch iu tr mi, nu ng l vim ty c kh nng phc hi ta c th trm lun bng Glass ionomer cement lp di v lp trn l Composite hoc Amalgam. 1.5.2. Vim ty khng c kh nng hi phc Ly ty tan phn: c th gy t ly ty hay t thuc dit ty 1.5.3. Hoi t ty: ly ty ton phn 1.6. Tin trin 1.6.1. Vim ty c kh nng hi phc Nu chn on ng v ty c bo v, ty c th tr v trng thi bnh thng, ngc li nu ty khng c bo v th triu chng c th dai dng hoc dn n vim ty khng c kh nng hi phc. 1.6.2. Vim ty khng c kh nng hi phc Nu khng iu tr ty s b hoi t.

26

1.6.3. Hoi t ty Nu khng iu tr vi khun, c t v sn phm phn hy Protein ca ty c th i ra khi chp gy ra bnh vng quanh chp.

2. BNH L VIM QUANH CHP

2.1. Nguyn nhn - Do vim ty, nhim trng ty - Do nhng sai lm trong iu tr ni nha: + Khoan ra ng ty y cc cht d bn ra ngoi chp + Trm ng ty ra ngoi chp rng + t thuc dit ty nhiu + Bng thuc st khun nhiu + Ly ty, trm ty st - Rng c ty bnh thng nhng b chn thng khp cn do ming trm cao hay do nghin rng. - Do vt l nh xng c, tm xa rng, lng bn chi nht vo k rng. 2.2. Triu chng 2.2.1. Vim quanh chp cp 2.2.1.1. Triu chng chc nng - Rng c cm gic tri cao, cn ng hm rng i din au - au d di v au lan ta n tai mt thi dng. 2.2.1.2. Triu chng thc th - Rng rt au khi g dc, g ngang au t, s c th hi au - Rng lung lay nhiu hoc t - Nu rng b vim - Ty rng c th sng hoc cht (cn th nhit v in) - X quang: dy chng nha chu c th bnh thng hay hi dy ln. 2.2.2. p xe quanh chp cp L mt trong nhng bnh l nha khoa nng - Tin trin ban u nhanh t nh n sng nhiu - au d di khi g v s - Rng b lung lay v tri cao hn - Trng hp nng bnh nhn b st - X quang: trn phim vng m quanh chp c th bnh thng 2.2.3. Vim quanh chp mn tnh 2.2.3.1. Triu chng chc nng

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- Thng rng khng c triu chng, ch xut hin l d nu tng ng vi rng au, m c th thot ra lin tc hoc gin on qua l d - Triu chng tan thn khng c 2.2.3.2. Triu chng thc th - Rng b i mu sm - Rng c th hi au khi g v s - X quang: c vng thu quang quanh chp (c th ln hay nh, lan trn hay gii hn r) - Th in khng c phn ng 2.2.4. p xe ti pht - L trng hp vim quanh chp mn bt thnh lnh c triu chng. - Triu chng ging vi p xe quanh chp cp, ch khc l p xe ti pht xy ra sau mt tnh trng mn tnh. - p xe ti pht c th bc pht t nhin, nhng a s l ngay sau khi iu tr ty trn mt rng c chn on l vim quanh chp mn khng c l d. - X quang c thu quang quanh chp 2.3. Chn on 2.3.1. Chn on xc nh Da vo triu chng lm sng 2.3.2. Chn on khc bit 2.3.2.1. Vim quanh chp cp: khc vi - Vim ty cp tnh: g ngang au nhiu, rng khng lung lay - p xe quanh chp cp: rng cht ty, cn vim khp cp rng c th cht ty hoc khng. 2.3.2.2. p xe quanh chp cp - p xe nha chu + Ty ang cn sng + C ti nha chu khi thm d c dch chy ra, sng t v sng gn c rng hn - p xe ti pht: X quang c vng thu quang quanh chp rng 2.3.2.3. Vim quanh chp mn - p xe ti pht: X quang c 1 vng thu quang quanh chp rng, km vi nhng triu chng ca p xe quanh chp cp. - Nang chn rng, u ht: cn lm sinh thit xc nh, nu l nang chn rng c cha nhng ht cholesterol, cn trong u ht l t chc vim mn tnh trong ty rng. 2.4. iu tr 2.4.1. Ti ch l ch yu 2.4.1.1. Vim quanh chp cp - Trng hp ty hoi t: m ty trng, sau iu tr ni nha - Ty cn sng: phi loi b cc nguyn nhn, v d, iu tr chnh khp cn

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2.4.1.2. p xe quanh chp cp Rch p xe theo ng trong ming hoc m ty trng cho that m, sau ty thuc iu tr ni nha hay nh b. 2.4.1.3. Vim quanh chp mn: iu tr ni nha 2.4.2. Ton thn Khi c triu chng ton thn iu tr phi hp khng sinh, khng vim v gim au. 2.5. Tin trin T vim quanh chp cp nu khng iu tr s a n p xe quanh chp cp, vim quanh chp mn. Nu tip tc khng c iu tr vi khun v c t ca vi khun s lan trn gy vim m t bo, vim xoang hm, vim xng hm./.

CU HI T LNG GI
Cu 1. Nguyn nhn nhn gy vim tu cp l: A. Su men. B. Vim nu. C. Su ng. D. Thiu sn men. E. Vi ho ng tu. Cu 2. Vim tu khng c kh nng hi phc c th gy nn: A. p xe nha chu. B. p xe ti pht. C. Vim quanh chp rng mn tnh. D. Vim nu. E. Vim quanh chp rng cp tnh. Cu 3. Khi b vim tu thng d b hoi t v: A. Mch mu tu nh nn nui dng t. B. Chp rng ng kn. C. Tu rng l mt khi m lin kt non. D. Tu rng b bao ph bi mt lp dy men v ng. E. Tu rng nm trong 1 xoang cng, kn v mch mu tu l mch mu tn cng. Cu 4. Triu chng ca vim tu c kh nng hi phc l: A. au m . B. au do kch thch v ko di vi giy sau khi ht kch thch. C. au t pht. D. au do kch thch v ht au khi ht kch thch. E. au do mch p. Cu 5. Vim tu kinh nin c du chng: A. au d di. B. G ngang au. C. au thong qua khi c kch thch. D. G dc au nhiu. E. au m lin tc. Cu 6. Chn on vim tu cp, ch cn da vo: A. Triu chng chc nng D. G dc. B. Phim X quang. E. Th in v nhit. C. Khm y l su v no ng mm

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Cu 7. Vim quanh chp cp khc vi vim tu cp im: A. au t pht. B. au lin tc. C. Cm gic rng tri v lung lay. D. G ngang au. E. au d di. Cu 8. iu tr vim tu cp cn phi: A. Che tu. B. Ly tu ton phn. C. t dung dch Eugenol. D. Dng thuc khng sinh. E. Ly tu bung. Cu 9. Triu chng chc nng ni bt ca vim quanh chp cp l: A. au t pht. B. au lan to. C. Rng c cm gic tri, cn au. D. au d di. E. au ko di. Cu 10. Vim tu nu khng iu tr s tin trin theo tun t: A. p xe quanh chp cp. B. Vim quanh chp rng mn tnh. C. Tu cht. D. Vim quanh chp rng cp tnh E. Tu hoi t.

TI LIU C THM
B Mn Cha Rng Khoa RHM H Y Dc TP HCM. (1998), Bi Ging Bnh L Rng

30

Chng 5

BNH NHA CHU

Mc tiu hc tp 1. Trnh by c cu to gii phu, chc nng sinh l m nha chu. 2. Phn tch c nguyn nhn, c ch sinh bnh ca bnh nha chu. 3. M t c nhng triu chng lm sng ca cc hnh th bnh nha chu. 4. Nu c phng php iu tr v cc bc d phng bnh nha chu.

1. NH NGHA
Bnh nha chu l bnh ph hy nhng c cu thnh phn nng rng nh nu, dy chng nha chu, ximng gc rng v xng rng.

2. DCH T HC BNH NHA CHU

Bnh nha chu c lin quan vi cc bnh khc ming v ton thn, cng nh s lin quan vi mi trng sng. Khng c bnh nha chu no thun ty, ring bit xut hin mt cch ngu nhin, m bao gi cng l kt qa ca mt hay nhiu xo trn, mt cn bng no ti ch nh rng mc lch, su rng, rng gi... hoc ton thn nh bnh suy dinh dng, i tho ng, yu t di truyn... Ngoi ra, m nha chu cn c mi lin h vi rng, vi khp thi dng hm, b my nhai v h thng min dch ca c th. Bnh nha chu l mt bnh lu hnh ph bin, chim mt t l kh cao trong cng ng v gp tt c cc la tui, cc vng a l t thnh ph n nng thn, t ng bng n min ni. Theo iu tra sc kho rng ming (SKRM) ton quc Vit Nam 1999 - 2000 ca Trn Vn Trng v Lm Ngc n, t l vim nu ca c nc nh sau: Tui 12 15 35-44 C nc 95% 95,6% 99,26% T.P H Ni 84% 96% 92% T.P HCM 100% 96% 100% Cao Bng 88% 92% 100%

- Hu, theo mu iu tra sc khe rng ming ca nhn dn thnh ph nm 1990, t l vim nu l 93, 57% la tui 12-15. - Cc nc trn th gii t l vim nu la tui 15-19 nh sau: n : nm 1989 l 96% Nepal: nm 1986 l 99% Thi Lan: nm 1981 l 100% c: nm 1984 l 63% Nht: nm 1987 l 88%

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3. S LC CU TO GII PHU V CHC NNG SINH L CA M NHA CHU

M nha chu l ton b nhng c cu nng rng v gip rng ng vng trn cung hm. C bn loi m ch yu: nu rng (li rng), dy chng nha chu (mng nha chu), ximng gc rng, xng rng (XOR). 3.1. Nu rng - L phn ca nim mc ming, cn gi l nim mc nhai, nu bao bc quanh xng rng v rng, m st c rng v tri di t c rng n ln tip hp nim mc di ng (y hnh lang ming). - Bnh thng nu c mu hng nht, rn chc, b mt nu c lm tm mu da cam. C th chia nu ra lm hai phn: 3.1.1. Nu ri (nu t do) L phn nu vin bao quanh c rng nh mt chic nhn, khng dnh vo rng, c gii hn vi nu dnh bi mt rnh nh gi l rnh nu ri. Nu ri rng chng 1mm v lm thnh vch mm ca khe nu (s d gi l nu ri hay nu t do v ngi ta c th dng cy thm d tch nu ri ra khi mt rng). - Khe nu l mt rnh nh hp hnh ch V, l ni tip xc gia nu ri v mt rng, khe nu cng bao quanh rng nh nu ri. Chiu su ca khe nu bnh thng l 0 - 3,5mm (cch nh gi trong iu tra dch t hc theo h thng CPITN ca WHO, h thng PSR ca M hoc h thng BPE ca Anh) l tng l 0 mm. y ca khe nu l ni bm ca biu m bm dnh (EA). Biu m bm dnh tri di t men rng ( y khe nu) n ln tip hp men- ximng, b rng ca di biu m ny khong 2,5mm. Khe nu gm 2 vch, vch mm l nu ri, vch cng l b mt gc rng, Trong khe nu thng xuyn tit ra mt cht dch st trng v ra sch khe nu. khe nu, biu m va mng li khng c ha sng cho nn c t vi khun d xm nhp vo m lin kt ca nu ri v gy nn vim nu. Chnh v vy, khe nu gi mt v tr quan trng l im xut pht cho nhiu hnh thc vim nu. - Gai nu (nu k rng) l phn nu gia 2 rng c hnh thp. Gai nu qu to hoc khng c gai nu lm mt thm m ng thi gy ng thc n, to nhng h hc k rng lm bnh nha chu pht trin. 3.1.2. Nu dnh L phn nu k tip phn nu ri tri di n ln tip hp nu - nim mc di ng. B rng ca nu dnh thay i t 0,5 - 6mm. vng khu ci khng c ranh gii gia nu dnh v nim mc. Nu dnh khng di ng, khng thay i di sc nhai, p st vo rng, bm cht vo ximng v xng rng. 3.2. Dy chng nha chu 3.2.1. nh ngha L mt cu trc m lin kt si bao bc quanh gc rng v ni gc rng vo xng rng. Dy chng nha chu l s ko di m lin kt ca nu, lin lc vi tu xng thng qua nhng ng nh ca phin cng. Chc nng l neo gi rng trong xng v duy tr mi quan h sinh l gia rng v xng . 3.2.2. Cu to - Gm ch yu l si collagen v si oxytalan xp thnh cc b si chnh.

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C 4 nhm: Nhm nh xng , nhm ngang, nhm nghing, nhm chp gc rng - Cc t bo: t bo si, t bo ni m, t bo to ximng, to ct bo, i thc bo, t bo biu m Malassez. - Dy thn kinh, mch mu v mch bch huyt. 3.2.3. Chc nng - Chc nng vt l: Dn truyn lc cn nhai n XOR v ni rng vi xng , thch ng c vi nhng c ng sinh l ca rng, gi gn mi quan h gia nu v rng, lm v bc che ch cho cc mch mu v dy thn kinh khi b chn thng bi lc c hc. - Chc nng dinh dng v cm gic: Nui dng ximng gc rng, XOR v nu, cc dy thn kinh to ra cm gic nh v v xc gic. - Chc nng c quan di truyn: Mng nha chu gi vai tr l mng xng cho ximng v xng rng, nhng t bo mng nha chu tham gia vo qu trnh tiu hu ximng v xng rng. 3.3. Ximng gc rng 3.3.1. nh ngha L mt lp xng do m lin kt to ra bao bc mt ngoi gc rng, c ngun gc trung b. 3.3.2. Chc nng L ch bm cho cc dy chng nha chu ni rng vo xng . 3.3.3. Cu to Ximng gc rng gm 2 lai: - Ximng gc rng khng c t bo: C c rng v 1/2 chn rng pha c rng. Lp ximng ny mng trong sut ngn cch r rt vi ng rng. Gm nhiu lp sp xp song song vi nhau v song song vi b mt gc rng iu chng t ximng gc rng c bi p theo chu k, rt chm v ko di c i ngi. - Ximng gc rng c t bo: C vng quanh chp gc,1/2 chn rng pha chp rng v ni chia 2, chia 3 ca rng nhiu chn v cng c hnh thnh tng lp mt. S bi p ximng gc rng xy ra lin tc sau khi rng mc chm rng i khng, gp phn cho qu trnh mc rng lin tc b p phn men rng b mn v lc nhai. Trong qu trnh mc rng, phn chn rng nm trong gim dn, do lm suy yu s gi vng ca chn rng. b p hin tng ny ximng gc rng c s bi p lin tc b mt gc. S bi p ch yu xy ra chp rng hoc vng chia ca rng nhiu chn. Ngi ta cho rng s h hi hoc ri lon cho s thnh lp ximng gc rng l mt trong nhng nguyn nhn gy ra ti nha chu v n khng cn gii hn c s di chuyn ca biu m bm dnh v m chp rng. Cho nn, v mt l do no ti ch (nh sang chn, cao rng, nhi nht thc n, v sinh rng ming km...) hoc ton thn (nh suy dinh dng, thiu vitamin A, D, lao...) lm cho s thnh lp ximng gc rng b tr tr, xo trn. S bi p ximng gc rng tng v tr c lin quan n tui nh: tui cng ln s bi p men vng c chm li, trong lc y s bi p vng chp gc li tng ln, tc bi p chm li tui gi. 3.4. Xng rng

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3.4.1. nh ngh a L ph n c a x ng hm, g m m t vch x ng m ng x p bao c ng chung quanh g c r ng l n i cc dy ch ng nha chu bm vo. 3.4.2. Chc nng Gi cho rng c vng chc, s vng chc ny ph thuc vo chiu cao ca xng . Xng tn ti cng vi rng, nu rng b nh b hoc khng c rng xng rng s b tiu. - Xng rng l mt ngun d tr canxi cho c th do n cng tham gia vo s cn bng can xi trong mu, v th xng rng cng b nh hng bi yu t ton thn v ni tit. - Xng rng l m km n nh nht so vi cc m nha chu khc, chu tc ng ca nhiu yu t trong yu t sang chn l quan trng. Tiu xng rng l mt du chng ng bun trong bnh nha chu v thng l do nguyn nhn ti ch (nh vim nu, chn thng khp cn).

4. NGUYN NHN
Bnh nha chu gm 2 nguyn nhn: ti ch v tng qut 4.1. Nguyn nhn ti ch 4.1.1. Nguyn nhn do vi khun Vi khun nm trong mng bm rng do vy mi s tch t mng bm vi khun chung quanh rng v nht l khe nu chnh l yu t khi pht v ko di phn ng vim nh: - Cao rng c thnh lp do s vi ha mng bm rng v n cng l ch dnh l tng cho cc lp mng bm k tip bm vo. Cao rng c th l trn nu hc di nu hoc c trn v di nu. - Nhi nht thc n Do h khong tip cn gia hai rng (xoang trm lai II sai hay phc hnh sai hoc do rng mc lch, nh rng khng lm rng gi). To s lu gi cc mng bm vi khun. - C s lin quan v nh hng bt thng ca rng k cn v rng i din (rng thiu chc nng hoc c nhng im vng cm mt nhai hay cnh cn) - Thng xuyn s dng ng v cc sn phm ch bin t ng m khng gi v sinh rng ming ng mc. 4.1.2. Sang chn do khp cn - Sang chn sinh ra do khp cn b lch lc, b xo trn nh: rng mc lch, trm rng v phc hnh rng sai, nh rng khng lm rng gi...Sang chn khp cn dn n tiu xng rng. - Ngoi hai nguyn nhn k trn cn c mt s nguyn nhn ti ch khc khc nh: th ming, kch thch t hm rng gi tho lp, li ln, thng mi v m bm thp... Nhng ni chung, nguyn nhn trc tip ch yu vn l do tnh trng v sinh rng ming km gy tch t mng bm vi khun.

4.2. Nguyn nhn ton thn

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4.2.1. Ri lon ni tit Bnh tiu ng, bnh thiu nng tuyn thng thn, ph n mang thai, tui dy th, ri lon cn bng chuyn ha. 4.2.2. Bnh c tnh ton thn nh ung th mu. 4.2.3. Nhng bnh nhim khun Vim ming v nu do lin cu, zona, giang mai giai on hai, vim ming herpes. 4.2.4. Suy dinh dng, tnh trng thiu vitamin C trm trng. 4.2.5. Yu t min dch Yu t nguy c: Khi nghin cu v vn dch t hc ca bnh nha chu, ngi ta khng th b qua yu t nguy c ca bnh nh: tui, gii tnh, chng tc, ngh nghip, tnh trng kinh t, x hi, a d, ch n ung, dinh dng c xem l c lin quan n mc trm trng ca bnh. - Tui: tng v t l v mc trm trng theo tui. S gia tng ny c th l hu qu ca nhiu ln vim hoc l s tng dn v mc ph hu do v sinh rng ming km hay do s thay i trong p ng ca c th. iu tra c bn SKRM quc gia 1990 t l ngi c ti nha chu nng l 29, 97% ti nha chu su l 2,36% nhm tui 35 - 44. Trong lc y, t l ti nng l khng ng k v t l ti su l 0% la tui 12 - 15. New Zealand (Tn Ty Lan) ch s nha chu (PI: periodontal index) tng ln t 0,89 tui 35 n 1,21 tui 64 Nh vy, bnh nha chu tng theo tui l r rt Vit nam cng nh nhiu nc trn th gii. - Gii tnh Khng c s thay i v tn s v mc trm trng ca bnh vim nha chu nam v n. Ch c s khc bit v t l chy mu nu la tui 15 - 19 n cao hn nam. Theo iu tra c bn nm 1984 ca B mn Nha chu - trng HYD thnh ph HCM th tui 35 tr ln nam b cao rng chy mu nu v t l bnh nha chu cao hn n c l do v sinh rng ming km hn. La tui 15 - 19 n chy mu nu nhiu hn nam. - Yu t x hi Ngi da en c bnh nng hn ngi da trng. T l bnh chu v chu Phi nhiu hn chu u, chu c v Hoa k. iu ny c th gii thch do s pht trin kinh t ca nhng nc ny km hn. - Ch n ung v dinh dng Ch dinh dng km dn n tc pht trin v mc trm trng ca bnh vim nha chu.

5. SINH BNH HC CA BNH NHA CHU

- Bnh nha chu l mt bnh nhim khun m nha chu, bnh xy ra khi c s mt cn bng gia mt bn l vi khun tp trung vi s lng ln v mt bn l nhng c ch bo v c m nha chu.

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- Sang chn vi nhng lc bt thng tc ng trn rng cng l nguyn nhn ti ch quan trng. Sang chn khng gy ra vim nhng gy ra tiu XOR v bin vim nu thnh vim nha chu. - Ngoi ra nhng c ch bo v ti ch cng b chi phi rt nhiu bi yu t tng qut c th l cc bnh tng qut nh tiu ng. Nguyn nhn tng qut s thc y qu trnh pht trin ca bnh t vim nu nh thnh vim nu nng hoc t vim nu thnh vim nha chu ph hy.

Yu t ti ch

Mng bm rng

Vi khun

Cao rng

Sang chn

Vim nu

Vim nha chu ph hu (VNCPH)

Yu t ton thn S 5.1: Sinh bnh hc bnh nha chu

6. CC HNH TH LM SNG BNH NHA CHU

Trong bi ny chng ti ch cp n nhng bnh nha chu ph bin nht: vim nu, vim nha chu ph hy, vim nha chu la tui thanh nin (suy nha chu). 6.1. Vim nu (gingivitis) 6.1.1. c im ca bnh - Bnh c tnh hon nguyn. - L mt bnh nha chu c sang thng khu tr nu, cc thnh phn khc ca m nha chu khng b nh hng. 6.1.2. Triu chng lm sng - Chy mu nu: khi thm khm hoc nh rng nu vim nng hn c chy mu t pht. - Mu sc: nu c mu m hoc xanh xm. - V tr, hnh dng v sn chc ca nu: vim nh ch nu vin v gai nu sng. Vim nng c phn nu dnh cng b nh hng, vin nu tr nn trn bng, cc gai nu cng phng, nu b khng cn sn chc. - au: vim cp tnh au nhc, nu vim mn ch c cm gic nga nu.

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- su ca khe nu: c s gia tng su ca khe nu do nu b ph n v sng to thnh ti nu (ti nha chu gi). - Tng tit dch nu v dch vim. 6.1.3. Chn on v chn on phn bit - Chn on xc nh da vo cc triu chng lm sng. - Chn on phn bit: vi vim nha chu ph hu c ti nha chu, rng lung lay, hnh nh Xquang c tiu xng rng theo chiu ngang. 6.2. Vim nha chu ph hy (Periodontitis) 6.2.1. c im ca bnh - L bnh ca ton th nhng m nha chu gm c nu, dy chng nha chu, XOR, ximng gc rng. c trng ca bnh l s mt bm dnh t t n nhiu v c th pht hin m t cch d dng trn lm sng v phim X-quang. - L mt bnh mn tnh x y ra nhng ngi ln trn 35 tui, khng phn bit gii tnh. - L bnh khng hon nguyn. - Bnh din tin theo chu k (thi k bc pht xen ln thi k yn ngh). 6.2.2. Triu chng lm sng - Vim nha chu ph hu c tt c cc du chng ca vim nu nh: nu sng , chy mu v r dch. - Ngoi ra rng lung lay v di chuyn cng l mt du chng c sm hoc vo giai on mun ca bnh. - Du chng c hiu l s hnh thnh ti nha chu. 6.2.3. X-quang C hnh nh tiu xng rng nh hay mo xng. 6.2.4 C ch to thnh ti nha chu Ti nha chu hnh thnh do s di chuyn ca biu m bm dnh v pha chp gc rng ng thi vi s tiu xng rng. Ti nha chu c hnh ch V trong ti c nhiu vi khun. 6.2.5. Bin chng ca vim nha chu ph hy - p xe nha chu. - Vim khp rng, vim ty o ngc. - Vim m t bo, vim xng hm, vim xoang hm. 6.2.6. Chn on v chn on phn bit - Chn on xc nh da vo cc triu chng lm sng. - Chn on phn bit: Vi vim nha chu la tui thanh nin trn hnh nh X-quang c tiu xng rng theo chiu dc. 6.3. Vim nha chu la tui thanh nin (Suy nha chu: Periodontosis) 6.3.1. c im ca bnh - L mt bnh mn tnh hay gp tui 12 - 26, t l n mc bnh nhiu hn nam gp 3 ln.

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- Xy ra trn nhng bnh nhn khe mnh, c tnh trng v sinh rng ming tt, cao rng, mng bm rng, su rng t. - Bnh tc ng ln cc rng ci th nht v cc rng ca c th c thm 1 hoc 2 rng ph km theo. - Nguyn nhn tng qut l ch yu cn nguyn nhn ti ch ch l yu t ph gip lm bnh nng thm. 6.3.2. Triu chng lm sng - Nu rng khng vim m teo. - C s mt bm dnh, rng lung lay v di chuyn bt thng, to khong h gia cc rng, giai on ny bnh nhn khng au, khng chy mu nu. Sau , do nhng kch thch ti ch vim bt u xut hin v tip theo l s hnh thnh ti nha chu, bnh c nhng triu chng lm sng ging vim nha chu ph hy (bnh nhn thng n khm giai an ny). 6.3.3. X-quang Xng rng tiu theo chiu dc hoc vt. 6.3.4. Chn on - Chn on xc nh da vo cc triu chng lm sng. - Chn on phn bit vi vim nha chu ph hu, suy nha chu nu teo v hnh nh X-quang xng rng tiu theo chiu dc

7. K HOCH IU TR
Cn i tng bc c th t v hp l vi nhng bin php nhm loi b nhng triu chng v du chng ca bnh, phc hi sc khe cho m nha chu. Ty theo tng hnh th lm sng ta c k hoch iu tr c th: 7.1. Vim nu - Hng dn v sinh rng ming - iu tr cc sang thng cp tnh - Ly cao rng trn v di nu - Loi b cc v tr gy tch ly tp trung mng bm rng: sa cha nhng yu t ti ch gy bt thng cho m nha chu (ming trm d, phc hnh sai). - X l b mt gc rng hay Ly lng gc rng - iu tr tm thi cc rng su - Nh nhng rng bt li hay khng cn hy vng iu tr bo tn. 7.2. Vim nha chu ph hy v suy nha chu L bnh khng hon nguyn v th mc ch ca vic iu tr l chn ng s pht trin ca bnh. K hoch c th: bao gm iu tr vim nu (t bc 1 n bc 7) phi hp iu tr nha chu: - C nh cc rng lung lay v di chuyn - Mi iu chnh khp cn

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- Phu thut nha chu - Phc hnh cc rng mt - Hn ti khm iu tr duy tr (3 - 4 thng mt ln)

8. D PHNG
Mc ch ca vic d phng bnh nha chu l bo v rng cho tng ngi hoc cho nhiu ngi trong cng ng rng tn ti sut i cng nhiu rng cng tt. Chng ta bit, nguyn nhn ca bnh nha chu l mng bm vi khun, mng bm gy ra vim nu v t mi pht trin thnh nhiu hnh thc bnh nha chu khc. Loi b mng bm iu tr vim nu hay phng nga vim nu phi l mc tiu chnh ca mi bin php d phng bnh nha chu. 8.1. D phng cp 0 Phi hp vi cc cp chnh quyn, cc ngnh nng cao mc sng ca nhn dn trong cng ng v mt vn ha x hi kinh t. Tuyn truyn phng bnh (chi rng k sau khi n, ch dinh dng thch hp, khng n vt...). 8.2. D phng cp 1 Khi bnh cha xy ra - Gio dc sc khe ci thin v sinh rng mng: hng dn phng php chi rng; cch dng ch nha khoa, tm xa rng, xoa nn nu. - Khm rng v Ly cao rng nh k, pht hin sm nhng tn thng. - Trm rng su, sa cha nhng phc hnh sai, ming trm sai k thut, sa cha nhng thi quen xu nh mt tay, cn ch. 8.3. D phng cp 2 Khi bnh xy ra - iu tr nhng du hiu hoc triu chng u tin ca bnh nha chu nhm ngn chn bnh pht trin. D phng cp 2 cng bao gm vic gio dc sc khe hng dn v sinh rng ming, Ly cao rng trn nu v di nc v iu tr ti nha chu nng. - Khm rng nh k, kt hp vi chp phim X-quang. 8.4. D phng cp 3 iu tr phc hi trnh ti pht bao gm: phu thut nha chu, phc hnh cc rng mt, mi iu chnh khp cn.

CU HI T LNG GI
Cu 1. Theo iu tra sc kho rng hm mt ton quc Vit Nam nm 1999 - 2000, vim nu l mt bnh ph bin gp nhiu nht la tui: A. 12. B. 15. C. 12 - 15. D. 35 - 44. E. 15 - 19.

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Cu 2. Dy chng nha chu: A. L t chc m lin kt c ngun gc trung b. B. Gm cc si Collagen d b t do lc cn nhai. C. Thnh phn chnh l cc t bo v mch mu. D. Chc nng ct rng vo xng . E. Chc nng nui dng men rng v ximng chn rng. Cu 3. c tnh ca nu dnh l: A. Dai v chc. B. Di ng c. C. Dnh cht vo men rng v ximng chn rng. D. C mu hng khng dnh vo men rng, to nn khe nu. E. B rng ca nu dnh khng thay i. Cu 4. Nguyn nhn ch yu ca bnh nha chu: A. Cao rng trn nu. B. Cao rng di nu. C. Mng bm rng. D. Ch n nhiu ng. E. Sc kho bnh nhn suy gim. Cu 5. Cc yu t nguy c ca bnh nha chu gm: A. Bnh tiu ng. B. Yu t min dch. C. Bnh lao. D. Ch n ung v dinh dng. E. Tnh trng thiu vitamin C. Cu 6. Du chng ch yu ca vim nha chu ph hy: A. Rng lung lay v di chuyn. B. C m. C. au m ko di. D. C ti nha chu. E. Cao rng di nu nhiu. Cu 7. Du chng ch yu chn on phn bit gia vim nu v vim nha chu l: A. Cao rng di nu. B. Chy mu nu. C. au nhc nhiu v c m. D. Tt nu. E. C ti nha chu. Cu 8. Bnh suy nha chu A. Thng xy ra la tui 35 - 44. B. L giai on tip theo ca bnh vim nha chu ph hy. C. Chu nh hng ca yu t dinh dng. D. Do nguyn nhn ton thn l ch yu. E. Do nguyn nhn ti ch gy nn l ch yu. Cu 9. iu tr bnh nha chu vic u tin phi lm l: A. Ly cao rng. B. No ti nha chu. C. Hng dn v sinh rng ming. D. iu tr cc sang thng cp tnh. E. Ly cao rng v iu tr cc sang thng cp tnh.

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Cu 10. D phng khi bnh cha xy ra bao gm: A. Ly cao rng. B. Chp phim X quang pht hin nhng tn thng sm. C. iu tr sm cc sang thng cp tnh trnh cc bin chng. D. Phu thut no ti nha chu. E. Phc hnh cc rng mt.

TI LIU C THM
1. Nguyn Cn (1998), Bi Ging Nha Chu Hc Tp 1, 2, 3. B Mn Nha Chu Khoa RHM TP.HCM 2. V Th Bc Hi (2003), Gio Trnh Nha Chu, B mn RHM Trng H Y Hu

41

Chng 6

VIM NHIM MING - HM MT

Mc tiu hc tp 1. Nu c nguyn nhn, cc giai on lm sng v bin chng ca vim m t bo vng hm mt. 2. Trnh by c x tr ban u v nguyn tc iu tr cc trng hp vim m t bo thng thng. 3. Thc hin c cc bin php d phng.

1. I CNG
Vit Nam, vim nhim vng ming - hm mt l loi bnh thng gp bt c la tui no. Bnh cnh lm sng c th nh, nn vic chn on v iu tr n gin, tuy nhin cng c nhiu trng hp chn on kh v iu tr phc tp, thm ch c th dn n nhng bin chng nng, nguy him n tnh mng nu khng chn on ng v x tr kp thi. C nhiu nguyn nhn dn n vim nhim vng ming - hm mt, nhng bi ny chng ta ch k n nguyn nhn do rng, v y cng l nguyn nhn hng u gy nn vim nhim vng ming - hm mt m chng ta thng gp trong bnh vin v cng ng. Mc d trong nhng nm gn y vi pht trin ca nn kinh t - x hi, i sng ca nhn dn ngy cng c nng cao v vt cht ln tinh thn, cng vi s tin b ln v phng bnh v cha bnh rng ming, song vim nhim cp v mn tnh do rng vn cn l vn quan tm ln ca cc thy thuc chuyn khoa Rng - Hm - Mt v ca ton x hi.

2. NHC LI GII PHU

T chc t bo l t chc lin kt lng lo, gm nhng b si keo, si chun, v nhng t bo lin kt t do, tt c xen k nhau. Nhng vng t chc m gm c nhng t bo m rt ln, hnh cu hay a din, lm thnh nhng thy hay m, c ngn cch bi nhng vch t chc lin kt x. Nhng mch mu nh v h thng lm ba trong vng hp thnh t chc lin kt hon chnh. H thng bm ca c - cn vo mt ngoi hay mt trong xng hm trn v hm di, ngn thnh nhng vng trong c t chc t bo. T chc t bo ny thng thng vi nhau mc du c nhng vch ngn cn - c, do vim nhim t vng ny d lan rng sang nhng vng khc. Nhng vng thng b vim nhim nh: Vng m, vng sn ming, vng cn, vng tuyn mang tai. 2.1. Vng m trc b trc c cn Gm nhng c bm da mt, gia cc c l nhng khoang t chc lin kt lng lo, ni hay hnh thnh p xe m. T chc t bo m ca m thng vi h thi dng v cung tip. 2.2. Vng sn ming Hnh thnh bi phn mm ng kn khoang ming pha di gm nhng vng quan trng nm trn v di c hm - mng nh vng di hm (di hm-mng), vng di li (trn hm-mng) v vng di cm. 2.3. Vng cn i t cung tip n b di xng hm di, pha trc l b trc c cn, pha sau l b sau cnh ln xng hm di. 42

Pha sau vng cn thng vi vng mang tai, pha trong vi khoang bn hu, pha trn vi h thi dng nng v su. V phng din gii phu, h chn bm hm v h di thi dng c m t thnh tng th ring, nhng v cng nm chung trong mt vng sau hm, thng b vim nhim do rng, nn v bnh l c m t chung l p xe h chn bm-hm. 2.4. Vng mang tai - Thnh sau l b trc c c-n-chm v xng chm. - Thnh trc l b sau ca cnh ln xng hm di. - Thnh trong: Gia cn lin c chn bm v dy chng trm - hm c mt khe lm thng vng mang tai vi khoang bn hu, qua khe ny tuyn mang tai ko di vo khoang bn hu. - Thnh trn tng ng vi ng tai ngoi. - Thnh di l gii hm i t c c-n-chm ti gc hm, ngn vng mang tai v vng di hm. - Cc thnh phn gii phu c trong vng mang tai. + Tuyn mang tai, ng Stnon, c cn, xng hm di, c chn bm trong, thnh hu vng amian, c c - n - chm, c nh thn, c trm mng, dy chng trm mng, dy chng trm hm, c trm li, c trm hu. + Mch mu v thn kinh mt i qua nhng thnh phn ni trn.

3. NGUYN NHN
3.1. Do rng - Trc ht l nhng bin chng do su rng, vim ty, tip theo l vim t chc quanh chp rng. U ht v nang rng hnh thnh quanh chp rng sm hay mun cng b vim, v t vim lan rng n t chc t bo v phn mm. - Sang chn rng (gy rn nt, ng gip, sai khp, gy) lm ty rng b cht sau b nhim khun. - Tai nn do mc rng sa, rng vnh vin, nht l rng khn (mc lnh, mc ngm). 3.2. Vim nha chu nht l khi c ti m, vi khun xm nhp trc tip vo t chc t bo 3.3. Do iu tr - iu tr ty rng, y t chc ty nhim khun qua chp rng, hn ng ty rng cha tt. - Ly cao rng - Nh rng: nhim khun sau nh hoc nhim khun do sang chn lm rch li, tn thng xng rng. - Tai bin do lm rng hm gi: mi rng lm tn thng rng sng, tho lp hm gi gy sang chn. - Tai nn do chnh hnh rng: lc ko qu mnh lm rng b cht tu. - Phu thut nha chu, phu thut hm mt, phu thut chnh hnh. 3.4. Nhng nguyn nhn khc - Vim ty xng hm, vi khun lan vo phn mm. - Gy xng hm, nht l gy h thng vi ming hoc ng gy i qua rng nhim khun.

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- Vt thng phn mm hm mt lm rch nt t chc, vt thng cht, d vt nm trong t chc. - Nhim khun tuyn nc bt: vim tuyn nc bt, si tuyn, si ng tit nc bt gy nhim khun. T nhim khun tuyn hay ng tit nc bt gy nhim khun phn mm tng ng. - Nhim khun da v nim mc nh vim nang lng, vim da, vim ming, nht mt (nhim t cu khun nng, inh ru). inh ru c th gy nhim khun nng. - Nhim khun amian c th gy p xe khoang bn hu hay quanh amian. - Vim xoang hm trn bin chng gy vim xng hm v sau nhim khun phn mm. Tai nn do k thut chc xoang gy nhim khun vo cc vng quanh hm. - Tai nn do gy t: thuc t, dng c khng v khun.

4. TRIU CHNG LM SNG

4.1. Th cp tnh Thng tin trin qua hai giai on 4.1.1. Vim thanh dch y l giai on u ca vim m t bo (thng ko di t 1 n 3 ngy). - V phng din gii phu bnh + C s co tiu ng mch ti vng vim, s co mch ny ch thong qua rt ngn. + Tip theo l s gin mch th pht, ko di lm tng lu lng mu ti ch (huyt tng, bch cu xuyn mch, thm vo t chc lin kt xung quanh, tun hon ti ch chm li, gy ph n ti vng vim. - V phng din lm sng + Ti ch au ti rng nguyn nhn v lan ra xung quanh, bnh nhn c cm gic au git nh mch p. Li vng rng au: sng , ph n T chc vng ny sng n lm y cc rnh t nhin, xa cc g xng, gii hn khng r, da cng , mt ch sng cng chc, nhit tng, hn ch c ng ca cc c bm da. C th gy bin dng khun mt, co kht hm tm thi. Nu sn ming th lm cho li kh c ng. + Ton thn: St nh khong 38 39 C, mch nhanh, ngi mt mi, c th c hch di hm bn sng. 4.1.2. Vim m (p xe) y l giai on tip theo ca vim thanh dch - V phng din gii phu bnh Nhng m c hnh thnh, m c mu vng xanh, thi hoc khng, c, dnh, lc u cc m ny ri rc sau gom t li thnh m ln, s t m l do s xung t gia vi khun v h thng bo v t bo (trong p xe gm c mnh vn t bo, vi khun, i thc bo...). - V phng din lm sng

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+ Ti ch Vng rng nguyn nhn vn au. Li xung quanh vng rng au , ph n, c m chy ra khi ta n vo Vng sng khu tr r, da b mt cng bng, c mu hay trng, S vo ch sng rt au, khng di ng, dnh vo b mt nng v su, khi ta n ngn tay vo th li vt lm, hoc khi ta khm bng hai ngn tay c du hiu chuyn sng (cm gic c dch bn di). C th vn cn co kht hm tm thi. + Ton thn St nh 38C, ngi mt, c th c hch di hm cng bn. 4.2. Th mn tnh 4.2.1. Nguyn nhn Thng do vi khun yu, do iu tr khng ng hay dng khng sinh khng hp l. 4.2.2. Lm sng y l mt m nh, xung quanh l t chc ht, c bao bc ngoi cng l lp v x keo. c biu hin: - Ni hn (hay mt cc trn, bu dc) trn da, mt chc, da ph trn b mt nhn, mu sc bnh thng hoc thm tm, s khng au, dnh vo da hoc ch thy mt di cng ni ln chy di t vim n rng nguyn nhn. - Hoc thy mt l r ra ngoi da, nim mc hay ngch li rng nguyn nhn thng xuyn chy nc vng hoc m trng khng hi.

5. TIN TRIN
M c th v v d ra da, nim mc, ngch li, vm ming, sn ming. Cc triu chng lm sng bin mt, bnh nhn c cm gic khi, nhng sau mt thi gian li ti pht li hay dn n cc bin chng.

6. BIN CHNG
Nu vim m t bo cp khng c iu tr c th dn n nhng bin chng sau: - Vim ty lan ta: Vim lan ta c mt vng t bo rng ln. - Vim xng ty hm - Vim khp, vim mng tim, thn - Vim khp thi dng hm - Vim c nhai - Nhim khun mu - T vong

7. CC TH LM SNG THNG GP
7.1. Vim m t bo khu tr nng Nguyn nhn thng do rng v thng tn t chc quanh rng, p xe ch khu tr nng cnh rng hay quanh xng hm mt vng gii phu nht nh. Vic iu tr khng phc tp v chng khi, tn gi ca th vim ph thuc vo tn gi ca vng gii phu. 45

7.1.1. p xe quanh chp (cung) rng p xe quanh chp rng cn gi l p xe rng, thng bt u ti vng quanh chp rng, nguyn nhn do tu cht hay ty hoi t. p xe c th hnh thnh ngay sau khi ty b thng tn, hay sau mt thi gian b sang chn, p xe t quanh chp nhng c th tin trin di mng xng, trn mng xng, vo phn mm. - Lm sng Giai on cp tnh c phn ng ton thn, st, sng to quanh vng chn rng au. Trc khi hnh thnh p xe, ch sng t chc quanh rng, s thy mt mng cng, bnh nhn rt au. Khi m hnh thnh, xuyn qua mng xng vo phn mm, nim mc tin nh, th c du hiu chuyn sng hay n lm. - X tr Trong giai on mi sng cng nn sc ming nc m, p gc m, dng khng sinh. Khi p xe hnh thnh, phi rch dn lu p xe im thp nht. Nu p xe di mng xng, phi rch qua mng xng, nu p xe qua mng xng vo phn mm, tin nh hoc mt trong xng hm th chn ch rch dn lu im chuyn sng, rch nng (t nim mc) sau lun kp cm mu u t m rng m. Trnh lm thng tn nhng thnh phn gii phu quan trng. i vi rng cn cn nhc, nu khng bo tn c hoc do khng th rch c qua xng th ch nh nh ch c nh mi dn lu c m khu tr trong rng , ngay c nh nng di s bo v ca khng sinh. Nh rng chm, nhim khun s lan rng vo t chc v c th gy nn nhim c ton thn hoc gy vim xng. Trong mt s trng hp c bit, m ng l tin trin ra da, th li lun vo di nim mc x ca li gy nn p xe di li v sau m s r ra mt ngoi hay mt trong ca xng hm. 7.1.2. p xe quanh thn rng p xe quanh thn rng gp bt c la tui no, thng thng l tui th u, thanh thiu nin, lin quan n thi k mc rng. Rng khn hm di hay gy p xe quanh thn rng. Triu chng in hnh l vim hch, co kht hm, au vng rng s 8 di. Triu chng ton thn: st, kh nut, sng n vng di hm v vng amian, bn hu. S cc vng ny bnh nhn rt au. Khm ti ch, thng c li trm che mt phn hay ton b mt nhai. Thm khm bng thm trm u t c th chm vo mt nhai di li. Sau khi qua triu chng vim cp, phi iu tr trit : - Nu rng khn mc ngm hay mc lch, khng th mc khi cung hm th ch nh nh. - Nu rng khn mc thng hoc cn dng lm tr cho cu rng, hay nu rng hm ln th 1, 2 b su, vim ty, tin lng phi nh th c th ch ct li trm v gi rng khn. Phi ct b ton b li ph, bc l hon ton mt nhai. Sau khi ct li trm nht gc tm it, hay loi bng phu thut, trong 7 ngy li ct lin so v khng ph tr li thn rng. Khi c ch nh nh rng khn th khng nn ko di qu v c th gy vim tr li hoc gy vim xng. Nn nh ngay sau khi qua giai on cp tnh. Thng thng rng khn trn t gy bin chng, nhng nu gy bin chng th cch x tr cng nh rng khn di.

46

7.1.3. p xe t chc quanh rng p xe quanh rng cp thng do vim quanh rng mn tnh gy ra, c th do rng cht tu hoc sang chn khp cn. Nhim khun bt u t li lan xung mt hoc nhiu chn rng. Thi k cp tnh thng bt cht, vi triu chng au d di, nim mc v mng xng quanh chn rng b vim, li b bong ra. X tr: gim au phi rch dn lu p xe ch thp nht, hoc ch c du hiu chuyn sng. Rch qua t chc mm, ti chn rng b bc l. Nu chn rng b bc l qu 1/3 th nn nh. Nu rng cn chc v xng rng cn bnh thng th c th bo tn. Cha bo tn gm c rch dn lu m, no sch t chc ht b mt chn rng. 7.1.4. p xe m Lm sng: sng thp, di mp v khng qu b nn xng hm di. Rnh mi - m sng y. Rng nguyn nhn thng l rng hm nh, rng hm ln di v trn. Nu l rng nanh th sng n c mi mt di. Khm trong ming: vng tin nh di sng thnh hnh chy, u sau thon nh dn ti li trm rng khn, cn u chy phnh to th chm rng hm nh. Du hiu c trng ca bnh: khi n vo ch m sng th m xut hin di li trm rng khn. V m t xa rng nguyn nhn (rng khn) nn p xe m cn gi l p xe di c tin nh di hay p xe c mt - hm. Tin trin: t rng (rng khn) nhim khun c th lan n tin nh ming, qua ch bm sau ca c mt vo vng c cn, qua mt trong xng hm vo vng trn mng, qua b sau c hm - mng vo vng di hm. X tr: rch dn lu theo ng trong ming hoc ngoi ming (t dng). ng trong ming: gy t, rch 1 - 2 cm vo ch phng ln nht, qua nim mch, lun kp cm mu vo m, m rng kp m thot ra, ri dn lu bng lam cao su. ng ngoi ming: gy t dc ng rch. Rch 1 - 2 cm, ch rch qua lp da trnh thng tn cc nhnh ca thn kinh mt. Lun kp m m nh trn. 7.1.5. p xe mi trn v mi di - cm - Hm trn Cc rng ca l rng bnh l. p xe t m nn mi hay vch ngn mi. - Hm di M di c chm - cm lm thnh p xe cm. M trn c chm-cm lm sng n mi di. Khi rng ca l rng bnh l. X tr: rch dn lu ng tin nh trong ming, iu tr bo tn hoc nh rng nguyn nhn. 7.1.6. p xe vm ming Chn rng trong ca rng hm ln v rng hm nh thng l rng nguyn nhn. Cng c khi c rng ca bn. Vm ming khng c t chc t bo m ch c nim mc x, cho nn p xe t di mng xng, lm phng nim mc ln nh "mt knh ng h". b li - thn rng cng c th hnh thnh p xe di mng xng, nht l tr em. cng l th p xe di li mng xng.

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X tr: m dn lu. Tri vi nguyn tc c in l m dn lu im phng nht, m y phi rch song song vi c rng, l ni thp nht. Lun kp, m m. C th dn lu bng mnh gc tm it vo ng rch tch 2 mp, lm thot m. Rt gc sau 48 gi. 7.1.7. p xe vng sn ming (vim ty sn ming Ludwig) - Bnh sinh Thng do nhim khun rng hm ln, nht l rng khn di, vim xng, gy xng hm di, si nc bt, lan trn p xe t cc vng k cn nh p xe vng di li, p xe vng mang tai, p xe tuyn di hm, p xe hch. Vng di hm c xem nh ni gy nhim khun quanh hm, v thng vi cc vng xung quanh: di li, di cm, h thi dng, khoang bn hu, vng mang tai. - Lm sng Giai on u: au nhiu di gc hm, mt trong xng hm di, nut au, nc bt chy nhiu, c th gy kht hm. Sng sm di gc hm, sau lan ra c vng. Giai on ton pht: du hiu ngoi ming: sng to vng di hm, gc hm, lan xung xng mng, pha trn lan ln m (phn di), pha trc n vng di cm, pha sau n vng bn c. Li b xng hm di b xa. Sng n thnh mt khi vi xng hm, mt chc, sau mm, ln. Da c mu sm hay trng, cng bng. n vo vng di hm v gc hm rt au. Du hiu trong ming: khm trong ming thng kh, v co kht hm nhiu. C th thy nim mc v rnh bn li vng rng hm ln sng n xung huyt, sng y sn ming, y li ln trn v ra sau. S thy mm ln hoc chuyn sng nim mc phn sau ca sn ming, mt trong xng hm. Tr trc amian xung huyt. Nim mc phn trc sn ming bnh thng. Du hiu chc nng: kht hm, n nut kh, li c ng hn ch. au t pht vng di hm, lan ra sau, ln tai, au khi nhai. Tnh trng ton thn suy yu, st cao, mch nhanh, mt ng. Qu trnh lm m thng tin trin vo vng di li, di cm. X tr: m dn lu theo ng ngoi da. Dn lu bng ng cao su, c nh vo da. Phi hp iu tr khng sinh. 7.2. Vim m t bo khu tr cc vng su 7.2.1. p xe vng c cn - Bnh sinh Nhim khun ca hai rng hm ln di v nht l rng khn. Cng c khi do rng hm ln trn. Do k thut gy t thn kinh rng di khng v khun. Do gy xng hm di, nht l khi ng gy i qua rng khn b nhim khun. M c th t su gia c cn v xng, hay nng gia c cn v da.

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- Lm sng c im ca p xe vng cn l kht hm nhiu, au v sng. Nhng du hiu lm sng r rng nht t 3 - 7 ngy sau khi khi bnh. Sng c ngoi v c th c trong ming. Ngoi ming: sng t gc hm ti cung tip, cng. Sng lan xung gc hm ti vng di hm v ng gia. Nu p xe nng gia c cn v da, th s c du hiu mm ln hay chuyn sng. Da cng, bng, sm. Sng c th lan ra trc ti vng m, lan ra sau ti vng mang tai. Trong ming: kh khm v kht hm. Nu m t su gia c cn v cnh ln xng hm di, th nim mc b trc cnh ln n, xung huyt, n lm. Nim mc thnh bn hu trc amian n , cn sau amian th vn bnh thng (phn bit vi p xe thnh bn hu: sng n ton b nim mc). Vng di li cng c th b sng. au: c th au d di, lan ln tai. C th kh nut. Tnh trng nhim khun ton thn, st, mt mi. - X tr Rch di v song song vi gc hm khong 3 - 4cm. V sng to vng gc hm nn kh xc inh chnh xc b xng v gc hm, v th, khong cch ng rch i vi xng nn ln hn bnh thng mt t. Qua da, c bm da, lun kp cm mu ln trn, ra trc vo vng cn, nu l m m su, th lun kp chm xng, tch cc th cn cn, i st xng m m. Banh rng kp, dn lu m bng ng cao su. ng trong ming: ch nh khi p xe tin trin vo su, gia c cn v cnh ln phng nim mc b trc cnh ln. Gy t dc nim mc b trc cnh ln. Rch nim mc b trc cnh ln, di khong 2cm, t trn xung di v pha xng. Lun kp cm mu vo gia mt ngoi xng v c cn vo m. Khng chc kp vo su qu khng lm tn thng mng xng v gy nhim khun vo cc vng k cn. Dn lu bng ng cao su hay mnh cao su (c nh vo nim mc) Cn phi trnh lm thng tn nhng thnh phn quan trng trn khi phu thut dn lu m . 7.2.2. p xe vng mang tai - Bnh sinh Do rng hm di v c khi do rng hm ln trn. Do vim m tuyn mang tai (thng gp). Do vim hch trong tuyn mang tai. Do lan trn nhim khun t cc vng k cn n (nh vng cn, thi dng...), hay do sang chn trc tip gy cnh ln xng hm di. - Lm sng Triu chng khi u t r, sng n vng mang tai, trc v di ng tai ngoi, sau sng lan rng c bn mt, lm cho n mi v mt b khp li.

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Rnh gia b trc xng chm v b sau cnh ln b sng dy, n lm v au. Da vng sng cng, bng, . Khm trong ming: kht hm, xung huyt nim mc m, c khi sng sau tr thnh bn hu. C du hiu nhim khun ton thn. - Chn on phn bit Vim tuyn mang tai v p xe tuyn: m chy qua ng Stenon khi n vo vng mang tai. 7.2.3. Vim m t bo ta lan (cellulite diffuse) hay phlegmon ta lan (phlegmon diffuse) Phlegmon ta lan l mt th vim t chc t bo cp, c c im lan ta rt nhanh v hoi t t chc khng gii hn, khng gy p xe t m r rt, do c t mnh ca vi khun tc ng trn mt c th v t chc ti ch km khng

8. CHN ON
Vim m t bo do rng thng khng kh. 8.1. Hi tin s Thng trc c au rng, vim nha chu hay mi mc rng. 8.2. Khm lm sng Thy hm rng tng ng vi vng b sng c rng su ln cht ty, hay rng b i mu do mt l do no , rng c th hi lung lay, g dc, ngang rt au; hoc rng khn mi mc, m b mc lch, hay b li ph ln trn. 8.3. Khm cn lm sng Chp X Quang: c th thy rng khn di ngm, lch, hoc di chn rng nguyn nhn c nhng u ht hay nang; tiu xng rng ca mt hay nhiu rng.

9. NGUYN TC IU TR
Khm t m lm sng, cn lm sng, ch nh iu tr l nhng qu trnh lin quan mt thit vi nhau. 9.1. Khm lm sng Trong vim m t bo do rng, khm lm sng c gi tr rt quan trng nh bnh ng v ch nh iu tr ng. Tm hiu lch s bnh, thng s thy bnh lin quan n mt nguyn nhn c th v rng, m quanh rng. Khm thc th ngoi ming, trong ming, nh khu vng sng, vng thm nhim, nhng ri lon chc nng nhai, ni, nut, kht hm... mc thng tn gii phu bnh xc nh chn on . 9.2. Cn lm sng Cn lm nhng xt nghim ch yu 9.2.1. Cy vi khun Phn lp cc loi vi khun gy bnh l rt quan trng, nht l trong trng hp vi khun khng li cc loi thuc khng sinh thng thng, c th phn lp cc vi khun hiu kh, k kh, c nm nu c iu kin. 9.2.2. Lm khng sinh

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Trong iu kin c th, cc bnh vin cng vi vic cy vi khun, cn lm khng sinh v xem nh l mt nguyn tc thng thng trong quy tc iu tr vim nhim, v mi loi vi khun nhy cm vi tng loi khng sinh. Trong trng hp khng c iu kin lm khng sinh th nn dng loi khng sinh c ph rng v theo nhng nguyn tc v s dng hp l thuc khng sinh. - Vic s dng khng sinh ngoi nhng nguyn tc, cn phi da vo kinh nghim. Dng khng sinh kp thi, ng liu lng l rt quan trng dp tt qu trnh vim v ngn nga cc bin chng. - V liu lng, nguyn tc chung l s dng liu mnh, phi hp, da vo kinh nghim v du hiu tin trin lm sng. 9.2.3. Cy mu Cn lm trong tt c nhng trng hp nhim khun nng, nht l trng hp nghi ng l nhim khun mu, ngi bnh c du hiu nhim c, hoc khi mi phng php iu tr trc t ra t hiu qu. Phi cy mu trc khi iu tr khng sinh. 9.2.4. Chp X quang Cn thit xc nh ng rng nguyn nhn. Nu bnh nhn h c ming phi chp phim ngoi ming nh chp hm chch i vi rng hm di. 9.3. iu tr chung Trong trng hp st cao hoc trong trng hp bnh nhn au khng ung c nc, c th a n tnh trng mt nc, cn phi b nc, vitamin, ng, theo ng tnh mch. Dng khng sinh phi duy tr cho n khi ht du hiu lm sng (nu l nhim khun mu phi tip tc dng khng sinh v theo di, khi no cy mu m tnh th mi chm dt). Dn lu nn dng ng cao su, mnh cao su v nn bng lng thot dch d dng, thay bng khi dch thm bn bng, bm ra qua ng dn lu hay ng rch bng cc dung dch: oxy gi, nc mui sinh l, dung dch khng sinh. Bm ra mt hay nhiu ln trong ngy ty theo m, dch tit nhiu hay t cho n khi ht dch, m. 9.4. Vn nh rng nguyn nhn C nhng kin khc nhau, c tc gi ch trng nn nh ngay rng nguyn nhn gy ra vim v va loi tr nguyn nhn, va dn lu qua rng. Tuy nhin c nguy c gy nhim khun lan trn, mt khc vic dn lu qua rng ch d i vi nhng vim nhim ti ch, cn khi vim nhim lan rng th rt hn ch. Hn na khi vim nhim do cc rng hm ln thng gy ra kht hm nn khng th nh rng c. V vy, vic nh rng ngay ch p dng c trong mt s trng hp. phng nhim khun lan trn, nhiu khi rt nng nh nhim khun huyt, vim tc tnh mch... ch nn nh rng sau khi dng khng sinh 1- 2 ngy v sau khi rch dn lu m, mt mt lm gim au cho ngi bnh, mt khc ngi bnh c th h ming c nh rng. 9.5. Vic bo tn rng Vic bo tn rng ch nn t ra vi rng mt chn nh rng ca, rng hm nh, trong iu kin tn thng cha nng lm v c th cha tt c, hoc nhng c s c iu kin theo di v c phng tin tt. Cn ni chung vi cc rng hm ln, nhiu chn, rng gy ra bin chng nghim trng th nn nh rng.

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10. IU TR
Ty theo giai on lm sng m ta c phng php iu tr thch hp. 10.1. Giai on vim thanh dch iu tr ni khoa l chnh, dng khnh sinh, chng vim, gim au; gi v sinh rng ming. C th khoan thng bung ty thot m lm gim p lc ti vng vim. Khi triu chng vim thuyn gim ta mi tin hnh nh rng nguyn nhn hoc gi rng li iu tr ty theo rng v kh nng ca ngi thy thuc. 10.2. Giai on lm m Vic trc tin l dn lu m: c th nh ngay rng nguyn nhn dn lu m hoc x dn lu bng ng trong ming qua nim mc hay ngoi da ty theo v tr khu tr ca m. Khng sinh, gim vim, gim au V sinh rng ming Gii quyt rng nguyn nhn: nh rng, cha rng hoc iu tr quanh rng. 10.3. Th mn tnh Dn lu m, nh hay cha rng nguyn nhn, no sch ng r.

11. D PHNG VIM M T BO

- Tuyn truyn v sinh rng ming cho cng ng - Khm nh k pht hin nhng bnh v rng ming - iu tr cc rng b su, vim li, vim nha chu... - Nhng rng khn mc lch, ngm gy bin chng cn phi nh phng vim m t bo - Nu pht hin vim m t bo cn c x tr sm trnh nhng bin chng nguy him

CU HI T LNG GI
Cu 1: Nguyn nhn hng u gy nn vim nhim vng ming-hm mt l: A. Chn thng vng hm mt B. Vim nha chu C. Sai lm trong iu tr D. Do rng E. Nhim khun tuyn nc bt Cu 2: Nguyn nhn no gy nn vim m t bo do rng? A. Chn thng hm mt B. Gy h xng hm. C. Vim tuyn nc bt cp. D. Vim quanh rng E. Vim ty xng hm Cu 3.Vim m t bo thanh dch v phng din gii phu bnh thy: A. Khng co tiu ng mch B. Co tiu ng mch thong qua . C. Co tiu ng mch ko di. D. Co tiu ng mch sau gin mch E. Co tiu ng mch gy mu ti ch

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Cu 4. Sng trong vim m t bo t m c cc c im sau y: A. Mu sc da bnh thng. . B. Lan ta ra xung quanh C. n vo thy cng chc. D. n vo li du lm E. Khng r gii hn gia t chc lnh v vim. Cu 5. p xe quanh cung rng thng: A. Gy bin dng khun mt. B. Bt u t vng quanh chp rng. C. Bt u t vng trn mng xng. D. Bt u t phn mm. E. Do vim ty rng cp tnh. Cu 6. p xe vng mang tai c th do: A. Rng hm (ci) ln hm trn B. Rng tin hm (tin ci), rng hm (ci) ln hm trn C. Rng tin hm (tin ci), rng hm (ci) ln hm di D. Rng hm (ci) ln hm di E. Do rng hm (ci) ln di, c khi do rng hm (ci) ln trn. Cu 7. Vim ty sn ming (Ludwig) c du hiu lm sng sau y: A . Ch sng mt bn sn ming B. H ming bnh thng . C. n, nut, th bnh thng D. Sng lan trn c hai bn sn ming E. Li c ng bnh thng Cu 8. Trong iu tr vim nhim vng ming-hm mt do rng, vic bo tn rng ch t ra i vi: A. Rng nhiu chn gy ra bin chng nghim trng B. Rng mt chn, tn thng cha nng lm c th cha c c s. C. Rng nhiu chn, tn thng cha nng lm c th cha c c s. D. Rng nhiu chn cha gy ra bin chng nghim trng E. Rng mt chn cha gy ra bin chng nghim trng Cu 9. iu tr vim m t bo thanh dch cn lm g trc: A. Khng lm g. B. Cho khng sinh, chng vim, gim au. C. X dn lu D. Nh ngay rng nguyn nhn E. Chc thm d. Cu 10. Cc phng php d phng vim m t bo cng ng phng php no d lm v hiu qu nht: A. Khm nh k pht hin vim m t bo. B. iu tr rng su C. Nh cc rng c th gy bin chng D. Tuyn truyn v sinh rng ming E. iu tr, vim li, cao rng.

TI LIU C THM
Trn Vn Qu (2005), Gio Trnh Phu Thut Hm Mt, Khoa RHM Trng H Y Hu

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Chng 7

CHN THNG HM MT
Mc tiu hc tp 1. Chn on ng cc loi vt thng phn mm v gy xng hm thng gp. 2. Trnh by c nguyn tc iu tr. 3. S cu, x tr bc u vt thng phn mm v cc trng hp gy xng hm n gin.

1. M U
- Trn th gii, t l chn thng ngy cng cao; trong , chn thng vng hm mt chim t l kh ln (theo D. Gallas, ring gy xng hm di chim 15 % gy xng chung) v thng lin quan n chn thng s no, gy t vong cao. - nc ta, cc loi tai nn lao ng trong sn xut cng nghip, tai nn sinh hot, th thao tng nhanh v s lng v tnh cht nguy him cho tnh mng c bit l tai nn giao thng (trong , tai nn xe my chim 70 %). Chn thng hm mt cng gia tng. Trc y, trong chin tranh, vt thng hm mt chim 7-10 % tng s vt thng v gy xng hm di nhiu gp 2-3 ln gy xng hm trn (theo bnh vin Vit c H Ni) nhng gn y, gy khi xng tng gia mt c chiu hng gia tng v t l vi tai nn giao thng. - Tnh hnh t ra cho ngnh y t nc ta mt nhim v nng n. Ngi thy thuc tng lai cn nm vng mc tiu hc tp c trang b c bn v kin thc, k nng v thi x tr thch ng, c th chm sc tt sc khe cho cng ng. Bi ny ch gii thiu v chn thng phn mm, gy xng hm trn v gy xng hm di .

2. CHN THNG PHN MM

2.1. c im gii phu, sinh l v bnh hc chn thng phn mm vng hm mt - Vng hm mt c nhiu mch mu v bch huyt nn c iu kin nui dng v bo v tt; v vy, vt thng thng chy mu nhiu nhng li chng hi phc. - Vng hm mt c mch mu nui dng phong ph, c hc ming, mi, mt v tai, do t c bin chng hoi sinh hi v v th vt thng vng hm mt c th khu ng kn th u (trc 6 gi) ngay c vt thng n mun (sau 6 gi) nu lm sch vt thng tht tt cng c th khu ng kn c. - C bm da mt mt u bm vo xng, mt u bm vo da nn vt thng c xu hng b toc rng v mp vt thng b qup li, co ko lm thay i cc mc gii phu. - Dy thn kinh mt chi phi vn ng cc c bm da mt d b tn thng trong chn thng hoc trong phu thut iu tr. - Vt thng mt khi lin so c th b co ko lm thay i cc mc gii phu, nh hng rt nhiu n chc nng n, nut, th, ni v thm m. - Tuyn nc bt v ng dn nu b t s to d nc bt ko di, gy kh chu cho bnh nhn. 2.2. Phn loi vt thng phn mm - Vt thng xy xt: cht da, rm mu gy au rt. - Vt thng ng dp: khng rch da, xut huyt di da gy i mu da tm thi.

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- Vt thng rch da: tu rng v su c th tn thng mch mu, thn kinh hoc cc t chc su. - Vt thng xuyn thng: thng su, lin quan n cc hc t nhin nh mi, ming, xoang hm... - Vt thng cht (tt): thng x toc t chc. - Vt thng bng: phn nh ngoi khoa. - Vt thng ho kh v chin tranh: thng bn, nhiu d vt, i khi cc mnh rng v xng tr thnh tc nhn ph hoi t chc (ho kh th pht). 2.3. Cc yu t tin lng Tin lng vt thng phn mm thng da trn mc nng nh ca cc yu t: - Chy mu - Ph hu t chc v ri lon chc nng. - S thiu hng t chc - Ngoi ra, bnh nhn c iu tr sm hay mun, sc khng ca c th l nhng yu t rt quan trng. 2.4. Nguyn tc iu tr - iu tr sm, s cu tt. - Thm d k, pht hin v ly ht d vt. - Chi ra tht sch. - Ct lc tht tit kim t chc. - Khu kn th u m bo chc nng v thm m. 2.5. S cu Cn tin hnh ngay ni xy ra tai nn, nhm loi b nhng nguy c n tnh mng. S cu c nh hng rt ln n tnh mng bnh nhn, s tin trin ca vt thng v kt qu iu tr. Ni dung s cu bao gm: - Chng ngt th: h hp nhn to, ly d vt ng th, vn chuyn bnh nhn ng t th: ngi u ci, nm nghing hay nm sp. - Chng chy mu: p vt thng bng tay, bng p, khu cm mu. - Chng chong: sm bng thuc tr tim, tr h hp, si m, truyn huyt thanh..., cm mu tt, trnh di chuyn bnh nhn nhiu ln v phi bt ng trc khi chuyn. - Chng nhim khun: bng kn vt thng, khng sinh phi hp. 2.6. ng vt thng th u Sau khi ly ht d vt, chi sch, ct lc v cm mu, c th tin hnh khu ng th u t m, t cc yu cu: - Khu ng tng lp t chc mt, khu mi ri. - Khng li khong cht c th ng dch, mu... - Khng lm sang chn thm t chc. - Nu vt thng thng vo ming, cn ng kn nim mc trc.

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- Khu da: + Khu da phi thng, u; nu vt thng cng c th khu Donati (xa-xa, gn-gn) xen k mi ri. + Nu vt thng thng, khng cng nn khu trong da bo m thm m. + trnh bin dng mt, cn khu cc mi kho hay cc mi mc nh gc mt, m mt, cnh mi, kho ming, ng vin mi... + Khi c thiu hng ln, cc mp khng che kn vt thng hoc qu cng, thng cc hc t nhin, l xng cn khu nh hng ko cc mp vt thng vo v tr gn bnh thng.

3. GY XNG HM TRN
3.1. c im xng hm trn (XHT) - XHT gm hai xng i xng nhau qua mt phng dc gia, gp phn chnh to nn khi xng tng mt gia, nn khi chn thng gy xng hm trn thng km theo chn thng cc xng tng mt gia khc nh xng chnh mi, xng l, xng g m, xng xon di, xng l ma. - C s lin quan mt thit vi hc mt, hc mi, xoang hm v nn s. Nn khi b chn thng thng nh hng nng n n cc c quan gic quan, s no. - L xng c nh, c che ph pha trn bi nn s v xng chnh mi, hai bn bi xng g m, cung tip xng thi dng v pha di bi xng rng, xng hm di nn ch b gy khi c chn thng trc tip v mnh. - L xng xp, c nhiu mch mu nui dng, nn khi b gy thng chy mu nhiu nhng xng chng lin, nn cn x tr cp cu. - C rng cm vo xng rng, quan h khp cn trung tm vi rng hm di, l c s t nhin gip nn chnh v c nh xng gy. 3.2. Phn loi gy xng hm trn Gy mt phn: gy xng rng, gy mm ln, gy b di xng mt, gc trong mt, ln h nanh, gy mm v vm khu ci. Gy ton b: c hai loi, gy dc v gy ngang. 3.2.1. Gy dc - Lannelogue: ng gy gia, tch ri hai xng hm trn, to k h gia hai rng ca gia, nim mc khu ci b rch. - Richet: gy dc mt bn qua rng ca bn hoc rng nanh. - Bassereau: phi hp Lannelogue v Richet chia xng hm trn thnh ba on. - Huet: ng gy hnh tam gic, nh l mu ln XHT, hai gc l hai rng nanh. - Walther: gm ba ng gy dc, mt gia, hai ng khc qua rng hm nh th nht hoc rng hm nh th hai, phi hp vi mt ng gy ngang (Le Fort I). 3.2.2. Gy ngang (cn gi l gy Le Fort) - Le Fort I (cn gi l Gurin) ng gy nm ngang t phn di hc mi, i sang hai bn trn cc chp rng ra sau n li c XHT, 1/3 di chn bm, gia v vch ngn mi v 1/3 xng l ma. - Le Fort II (tch ri s mt gia, di xng g m)

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ng gy bt u gia xng chnh mi, qua mu ln XHT n thnh trong hc mt, tn thng xng l, vo sn mt ri b di mt, sau chy gn hay ngang qua l di mt. Tip tc i di xng g m ra li c XHT, on ny song song vi LeFort I, pha sau gy 1/3 gia xng chn bm, gia gy 1/3 gia xng l ma. - Le Fort III (tch ri s mt cao, trn xng g m) vi cc ng gy ng gy bt u trn xng chnh mi, ngang hay trn ch ni khp xng trn, tch khp mi trn, n mu ln XHT, vo thnh trong mt gy xng l, xng giy, ri n khe bm, gy 1/3 trn xng chn bm Tch ri khp trn - g m Tch ri cung tip - g m Gy 1/3 trn xng l ma.

Hnh 7.1: Cc ng gy Lefort [11] Lefort I : Lefort II : Lefort III :

3.3. Lm sng gy ngang ton b xng hm trn 3.3.1. Le Fort I - Triu chng lm sng + Bnh nhn chong nh + n nhai kh, nut vng v phn gy sa xung. + Mt bin dng: mi trn sng n, bm tm, ming h ca, chy mu mi. + Trong ming: ngch li mi, li m bm tm, c th thy xut huyt hnh mng nga vm ming sau vi ngy. Khi cn, khi rng hm chm sm, h ca. + n t gai mi trc n XHT bnh nhn au chi. + Du Gurin: n sau li c XHT vng chn bm hm bnh nhn au chi. + Lc cung hm s thy di ng ton b (du hiu "eo hm gi"). - X quang: Pht hin ng gy nh phim s thng v s nghing.

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3.3.2. Le Fort II - Triu chng lm sng: + Bnh nhn chong + au dc ng gy gc mi b di hc mt, ni tip gip xng g m. C th b t mt do tn thng l di mt, chy mu mi, nhai vng au. + Xp phn gia mt do khi rng ca ln ln trn v li ra sau, bm tm mi di, chy nc mt do chn p ng l t. + Trong ming: sai khp cn do khi rng hm b y xung di v ra sau nn khi cn, rng hm chm sm. Ngch li vng rng hm bm tm, n au, ngch li tip gip xng g m c th c hnh bc thang. + n au gc trong, b di hc mt, gc mi, b di xng g m, li c XHT. - X quang: Blondeau, Hirtz, phim s thng v s nghing. 3.3.3. Le Fort III - Triu chng lm sng + Bnh nhn chong nng + au dc ng gy khp mi trn, trn-g m, g m-cung tip, chy mu mi, c th chy dch no ty + Mt ph n, bm tm quanh hc mt (du "eo knh rm"), nhn cu c th b lm hoc sp gy song th. + Trong ming: sai khp cn khi rng hm chm sm, h vng rng ca, bm tm vm ming. + C th s thy cc u xng di lch + Ton b khi xng mt di ng so vi khi xng s. - X quang: Blondeau, Hirtz, phim s thng, s nghing v ct lp vi tnh (CT Scanner). 3.4. Chn on gy ngang ton b xng hm trn Da vo v tr ng gy, triu chng lm sng v X quang. 3.5. iu tr 3.5.1. Nguyn tc iu tr - u tin cp cu tnh mng, ch iu tr chuyn khoa khi bnh nhn that khi hn tnh trng nguy him. - L mt cp cu, cn iu tr sm, khng b st tn thng, phc hi tt chc nng, thm m, ngn chn bin chng, trnh di chng. - Lu chc nng cc gic quan. 3.5.2. Cc bc iu tr 3.5.2.1. S cu - Ton thn + Chng chong Chong hay gp l chong mt mu, chong chn thng v chong nng trong trng hp chn thong vng hm mt km chn thng s no hoc a chn thng.

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iu tr chng chong theo nguyn nhn. Lm thng thong ng th: ngt th thng do cc nguyn nhn nh d vt (rng gy, hm gi, cc mu ng, d vt t bn ngoi...), li tt ra sau, ph n vng sn ming li do mu t, mt phc hp mng li (trong trng hp vt thng ho kh). Cn x tr lm thng thong ng th ngay bng cch: bnh nhn nm nghing phng mu cc, nc bt, cht nn vo ng th, kim tra d vt hng, thanh qun k c rng gy, rng trt khp, hm gi b v. Ko li ra trc bng cch khu ch xoa qua li, c nh bng canun Mayo hay Gudel. Pht hin mu t sn ming, li, vm ming mm lan rng gy cn tr ng th. Kim tra thng tn thanh kh qun, kim tra cc nguyn nhn khc phi hp gy km thng kh (hn m, chn thng lng ngc...). + Cm mu Chy mu nhiu c th t vt thng, t ng mch ln hoc v xng nhiu mnh. Chng chy mu mi: t bc mi trc v bc mi sau Khu vt thng da mt tht ng mch (cnh ngoi) nu cn Cm mu nhng vt thng cc ni khc. + Chng nhim trng Cn dng huyt thanh phng un vn hoc gii mn cm, khng sinh phng v iu tr nhim trng. + Chng vim, gim au ti ch Nn chnh bng tay hoc buc ch thp qua mt nhm rng ko chnh theo khp cn trung tm. C nh tm thi bng bng cm nh phi hp bng bng trn chm. + Chuyn bnh nhn ln tuyn trn iu tr tip Nu bnh ang tnh trng mt tri gic hoc ang trong tnh trng e do tnh mng th phi bnh nhn trong t th nm sp mt hoc nghing u trong qu trnh vn chuyn. Ht m di lm thng thong ng th. 3.5.2.3. iu tr chuyn khoa - Nn chnh bng tay, bng dy thp ko, mng chnh hnh, buc ch thp vo rng hai hm, to cc mc Ivy ci tin, lin hon Stout ko chnh lin tc bng cao su, ko qua xng Nlaton lun qua mi hng, s dng b dng c ngoi (Rudko). Phu thut khi xng lin. - C nh bng cung Tiguerstedt hay Ginested, bng mng vi b dng c ngoi. Phu thut treo xng hm vo g m, cung tip trong gy Le Fort I, Le Fort II (Phu thut Adams), hoc treo xng hm vo mu mt ngoi ca xng trn trong Le Fort III (phu thut Thomas). Thi gian c nh: 15-30 ngy.

4. GY XNG HM DI
4.1. c im xng hm di (XHD) - XHD l mt xng l, i xng, to nn tng mt di, ni ln vng c v mt, c nhiu im nh (cm, gc hm) nn rt d gy (theo D. Galas, chim 60% gy xng vng mt). - C h c nhai bm tn, lc tc dng i khng, nn sau khi gy, XHD thng b bin dng th

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pht. - L xng di ng, c rng cm vo xong rng, quan h khp cn trung tm vi rng hm trn c nh, l c s gip nn chnh v c nh xng gy. Rng khn hm di c vai tr quan trng trong gy xng hm di vng gc hm. - L xng dt, mng, ngoi c, trong xp, ch c nui dng vi ng mch rng di, nn khi gy t chy mu nhng chm lin xng. - C cc im yu d gy: khp cm, gc hm, l cm, li cu... 4.2. Phn loi gy xng hm di 4.2.1. Gy tng phn Gy xng rng, v li cu, mm vt, b di XHD, xuyn thng xng. 4.2.2. Gy ton b - Mt ng: gy vng gia, vng bn, vng gc hm, cnh ln, li cu. - Hai ng: gy i xng, khng i xng. - Ba ng, phc tp.

Hnh 7.2: Gii phu nh khu xng hm di 1: mm vt. 2: li cu. 3: cnh ln. 4: gc hm. 5: Xng rng - rng. 6: cnh ngang. 7: khp cm

4.3. Lm sng gy tan b xng hm di mt ng 4.3.1. Gy vng gia (khp cm) Chim 12% - V tr ng gy nm gia mt xa hai rng nanh, him khi ng ng gia m thng nm cnh khp cm. ng gy c th thng hay hnh lambda, tch ri li cm. - Triu chng lm sng + Sng vng cm, bm tm t mu, c th rch da mi, cm n au, li, ngch li mi, sn ming bm tm hay rch. + K hai rng ng gy i qua gin rng, Rng c th lung lay, gy hoc mt.

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+ Khp cn c th sai t hoc bnh thng do lc c cn bng. + Pht hin ng gy bng cch ng trc bnh nhn, dng hai tay, ngn ci t ln cung rng v ngn tr, ngn gia t vo b di cnh ngang, lm ng tc di chuyn ln xung ngc chiu s thy hai on gy di chuyn theo. C th dng ng tc b nh cung rng sang hai bn l ng nt. - X quang Pht hin ng gy nh phim Simpson, phim gc rng. 4.3.2. Gy vng bn (cnh ngang) Chim 30%, lu thng gy km li cu bn kia. - V tr T mt gn rng hm nh th nht n mt xa rng hm ln th hai, ng gy thng ko xung di v ra sau, thng i cnh hoc ngang qua l cm. - Triu chng lm sng + Bnh nhn au, khng nhai c do vng; nut vo pht m kh. + Mt bin dng, cm hi lch v pha gy, da vng m c th xy xt hay rch, sng v t mu di da c th lan rng ln m, xung c. + S b di v mt ngoi XHD c bc thang n au chi. + Trong ming c bin dng cung rng: on ngn v pha li cao hn on di, on di lch ra ngoi thp hn on ngn. Khi bnh nhn ngm ming rng an ngn chm rng hm trn trc ri n rng on di (triu chng rng chm khp hai ln do tc ng cc c c lc i khng) rng c th b gy, lung lay hay mt. Li, ngch li, sn ming c th b rch, chy mu. - X quang Pht hin ng gy nh phim hm chch (Maxillaire Dfil), phim gc rng, phim ton cnh (Panorama), phim s thng. 4.3.3. Gy vng gc hm (Gonion) Chim 18% v vng gc hm l im yu ca xng hm di. - V tr: t mt gn rng khn n gc hm, ng gy thng cho xung di v ra sau, vt thng thng kn tr khi qua rng khn to gy h. - Triu chng lm sng + Bnh nhn au t, nhai kh. + Vng gc hm c sng bm tm n au, mt thng khng bin dng nu c bin dng th hm s lch v pha gy. + Khm trong ming: khp cn thng khng di lch, n vo ngch li m vng gc hm, rng khn, tam gic sau xng hm di bnh nhn au. + Pht hin ng gy bng cch ng sau lng bnh nhn, mt tay c nh cnh ln, tay kia t ngn ci ln cung rng, cc ngn khc b di XHD, lm ng tc b cnh ngang ra trc. Trng hp c di lch, cnh ln b ko ln trn, ra trc v vo trong, cnh ngang b ko xung di v ra sau.

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- X quang Pht hin ng gy nh phim hm chch (Maxillaire Dfil), phim gc rng, phim s thng. 4.3.4. Gy cnh ln Rt him gp (7%) - ng gy C th nm ngang, dc hay hnh hoa th. - Triu chng lm sng + Bnh nhn au dc ng gy, kh h ming, kh n nhai. + Cm hi lch v pha gy, sng n bm tm vng c cn. + Rng thng chm khp hai ln v bn gy thng b ko ln trn. - X quang Pht hin ng gy nh phim hm chch (Maxillaire Dfil), phim s thng. 4.3.5. Gy li cu Nng xy ra, chim 32%, thng ba v tr:

Hnh 7.3: Gy li cu

1: chnh li cu
2: di li cu cao 3: di li cu thp

4.3.5.1. Di li cu thp (Sous condylienne basse) - ng gy nghing xung di v ra sau nn c li cu v ngoi khp. an li cu b ko ln trn ra trc, vo trong do tc ng ca c chn bm ngoi nhng di lch t, on cnh ln b ko ln trn, ra sau do tc ng ca c cn. - Khm + Dng ngn tay tr n gia np tai v li cu, bnh nhn s au chi trc np tai. + Dng hai ngn tay t t trc ng tai ngoi hai bn, bo bnh nhn h ngm ming so

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snh c ng ca hai li cu. + Trong ming: cung hm lch v pha gy, rng chm khp hai ln.

B
Hnh 7.4: Cc phng php c nh gy xng hm [11]

A: c nh rng hai hm bng ch thp theo Leblanc v Black Ivy B: kt hp xng bng ch thp v np vt

Hnh 7.5: Kt hp xng bng cc bn np vt nh [11].

Hnh 7.6: Phng php c nh hai hm bng cung Tiguerstedt [11]

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4.3.5.2. Di li cu cao (Sous condylienne haute) - ng gy nm ngang c gii phu ca li cu trong khp. u li cu b trt vo trong xung di v ra trc bi tc ng ca cc c chn bm ngoi. - Khm thy mt c ng li cu bn gy, au v t mu trc np tai, h khp ca, hm lch v pha gy, rng chm khp 2 ln, bn gy chm sm. 4.3.5.3. Chnh li cu (condylienne vraie) Triu chng lm sng ging gy di li cu cao, thng phi hp gy xng nh, hm cho v cung tip xng thi dng. X-quang pht hin gy li cu nh phim Schuller, Zimmer, s thng. 4.4. Chn an gy xng hm di ton b mt ng Da vo v tr ng gy, triu chng lm sng v X-quang. 4.5. iu tr gy xng hm di 4.5.1. Nguyn tc iu tr - L mt cp cu tr hon, c th iu tr trong iu kin c sa son, khi loi tr cc nguy him n tnh mng bnh nhn. - Phc hi tt chc nng n nhai, ni, nut. - Lu thm m, trnh cc bin chng, di chng. 4.5.2. Cc bc iu tr - S cu + Ton thn: chng chang, thng kh, cm mu, chng nhim khun. + Ti ch: nn chnh c nh tm thi bng cch buc ch thp lin kt cc rng hai u gy bng nt s 8, nt hnh bc thang, nt Ivy..., c nh tm thi hai hm bng bng cm nh v tng cng bng trn chm. - iu tr chuyn khoa + Nn chnh: bng tay, lc ko, b dng c ngoi hay phu thut. + C nh hai hm bng phng php Leblanc, Black v Ivy, phng php buc lin hon Stout hay s dng cung Tiguerstedt, Ginested. + Vi bnh nhn mt rng: c nh bng mng chnh hnh. + Phu thut trong cc trng hp kh iu tr chnh hnh nh gy vn, nhiu on hoc di lch nhiu: kt hp xng bng np vt, ng inh, phu thut buc vng quanh XHD cho tr em c b rng hn hp. + Phi hp kt hp xng vi c nh hai hm t 4-6 tun, hoc np vt v c nh bng thun trong vng 10 ngy u. + Ni chung, thi gian c nh t 30-45 ngy.

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CU HI T LNG GI
Cu 1. Nguyn nhn ch yu ca chn thng hm mt hin nay: A. nh nhau B. Tai nn sinh hot C. Tai nn giao thng D. Th thao E. Tai nn lao ng Cu 2. S cu ton thn trong chn thng hm mt l: A. Loi b nguy c nh hng tnh mng B. Chi ra vt thng tht sch C. Khu vt thng ng phng php D. To hnh thm m E. Ly ht d vt Cu 3. Gy xng hm trn l mt cp cu v: A. Chy mu nhiu B. Thng gy rng v xng rng C. Thng gy km xng chnh mi D. Thng gy km xng g m E. Chn thng trc tip v mnh Cu 4. Gy Le Fort II l: A. Tch ri s mt thp, di xng g m B. Tch ri s mt gia, di xng g m C. Tch ri s mt cao, di xng g m D. Tch ri s mt gia, trn xng g m E. Tch ri s mt cao, trn xng g m Cu 5. Du Gurin c trong gy xng hm trn loi: A. Le Fort I B. Le Fort II C. Le Fort III D. Lannelogue E. Richet Cu 6. S cu ti ch gy xng hm trn (XHT) l: A. Treo XHT vo xng g m B. Treo XHT vo mu mt ngoi C. Nn chnh bng tay, c nh bng cm-nh D. C nh cung Tiguerstedt E. C nh theo Stout Cu 7. Xng hm di d gy v: A. L xng di ng B. C nhiu im nh ni ln gia c v mt C. C h c nhai bm tn vi lc i khng D. C rng cm vo xng rng E. Ch c nui dng bi ng mch rng di Cu 8. V tr gy ng gia xng hm di: A. Gia mt xa hai rng nanh B. Gia mt hai rng ca gia C. Gia mt gn hai rng ca bn D. Gia mt gn hai rng nanh E. Gia mt xa hai rng ca bn

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Cu 9. Phim thng c ch nh trong gy vng bn xng hm di: A. Hm chch B. Schuller C. Mt nghing D. Mt thng E. Parma Cu 10. Gy xng hm di l cp cu tr hon v: A. C di lch th pht B. Khng km chn thng s no C. t chy mu, lin can chm D. Khng lin quan vi c quan gic quan E. Cn u tin thm m.

TI LIU C THM
1. V Th Quang (1973), Phu Thut Ming-Hm Mt , NXB Y Hc. 2. B Mn RHM H Y H Ni (2001), Bi Ging Rng Hm Mt, NXB Y Hc

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Chng 8

D TT BM SINH HM MT
Mc tiu
1. Trnh by c c im dch t hc, c ch bnh sinh v nguyn nhn ca d tt bm sinh hm mt. 2. Nu c cc dng lm sng, phn loi v nguyn tc iu tr c bn ca khe h mi vm ming (KHM-VM) 3. T vn c cho bnh nhn v ngi nh bit cch chm sc trc phu thut, thi gian v c s phu thut.

I. C IM DCH T HC
- Nhng d tt bm sinh vng hm mt, ch yu l nhng khe h vng mt, gy bin dng mt lm tn thng n tm l, thm m v chc nng, chim t l cao nht trong cc loi d tt chung ca c th (khong 10%). - c, t 1925-1958, thng k ton th tr s sinh th d tt chung ( chn, tay, thn kinh, tim, mch mu ln v hm mt) chim 0,6 - 2%, trong 1/10 l khe h bm sinh hm mt. - Tip Khc, c 200 tr s sinh, c 1 tr d tt bm sinh chung (theo Burian). Ni chung, trn th gii c 1000 chu mi sinh, th c 1 chu c d tt bm sinh vng hm mt (t l 10/00). T l ny c khc nhau mi nc v cc thi im khc nhau: - c : Trc th chin th II : 1/1000 Sau th chin th II : 1/450 - Tip khc : u th k 20 : 1/1000 Nm 1962 : 1/750 (theo Burian) - Php : 1/ 942 (1927 theo Veau v Peron) - M : 1/ 700 - Nht : 1/ 378 (Theo ti liu thng bo ca ngnh Rng Hm Mt M 9/1969). - Vit Nam, theo Nguyn Huy Cn, Vin bo v b m tr em, t l cng xp x 1/1000 (1996), Phm Gia c: t l 1/640 (1970). Theo Mai nh Hng, Vin RHM H Ni, t l 1/1211 (1980, theo Nguyn Th B Thanh, Vin ph sn thnh ph H Ch Minh t l 1/480 (1984). Tm li, khe h d tt bm sinh vng hm mt l mt bnh kh ph bin. Nu dn s nc ta hin nay l 80 triu dn, t l sinh l 3%, t l d tt bm sinh hm mt l 1/1000, th hng nm c khong 2400 chu nh ra i c d tt bm sinh hm mt.

2. C CH V NGUYN NHN BNH SINH

2.1. Nhc li khi nim bo thai hc Trng th tinh s phn chia ngay v tin trin qua cc giai on: Phi du, phi kt, bn phi hai l (khi xut hin ti i v non hong), sau l giai on bn phi 3 l (khi l trung b phi xut hin gia 2 l ni v ngoi b). Trong qu trnh pht trin, bn phi ngy cng n rng, li vo trong khoang mng i v rnh mng i ngy cng b h thp xung pha bng. Kt qu l khc u v khc sau ca bn phi ngy cng c phn bit r, l giai on khp mnh phi. Cng vi s pht trin mnh ca no, tim, thnh trc lng ngc, cung mang. Mm nguyn thy cng xut hin phn trn ca cung mang I.

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2.2. C ch bnh sinh gii thch c ch bnh sinh, ngi ta dng thuyt n mm ca Rhatke(1832), Dursy (1869) v His (1888), vo nm 1930 Victor Veau b xung thm bng thuyt tng chm (Mur plongeant). Theo thuyt n mm, vo tun l th 3 ca bo thai, lc thai khang 10mm, cung mang I v ti no I v tim pht trin nhanh, gia 2 khi no v tim hin ra 1 ch lm gi l mm nguyn thy, b chung quanh ca mm nguyn thy chi ra 5 n, c gi chung l n mt. N trn xut hin b trn ca mm nguyn thy, hai n hm trn hai bn v hai n hm di phn di ca mm nguyn thy. T n trn xut hin nhng n mi phi (MP) v mi tri (MT), c ngn cch bi khe gia, mi n mi phi v tri li tch lm i, thnh n mi trong v n mi ngoi, hai n ny c ngn cch bi rnh khu. Gia n hm trn v n mi c xut hin khe mt mi (khe OMM). - Nhng n hm trn cng vi n mi trong pht trin v gn dnh vi nhau, lm khp rnh khu, to thnh l mi v mi bn hm trn. - Nhng n hm trn v n mi ngoi (MN) cng pht trin v gn dnh vi nhau lp khe mt mi, li rnh gi l rnh mi l, v sau cng bin mt. - Nhng n mi trong pht trin v gn dnh vi nhau ng gia, to thnh mi gia hm trn (nhn trung) - Nhng n hm trn v n hm di cng gn dnh vi nhau to thnh s lin tc ca m Nh vy l ming l mt khe c 2 mi: mi trn c cu to bi nhng n mi trong v n hm trn. Mi di c cu to bi hai n hm di. Ngi ta gi giai on ny l giai an hnh thnh vm ming s pht gm phn mi v xng rng, t l khu ci trc (l rng ca) tr v trc.

Rnh khu N trn Mm nguyn thu N hm trn

Article I.

N mi trong N mi ngoi

Hnh 1: S hnh N hm d i thnh ca vm ming s pht (Formation du palais primaire)

Hnh 8.1: S hnh thnh vm ming s pht (Formation du palais primaire) [26]

Vo tun th 8 khi bo thai khong 30mm, bt u c s hnh thnh vm ming th pht, gm phn sau l khu ci trc ngn cch h ming v hc mi. Vm ming th pht c hnh thnh xut pht t l khu ci trc tr v pha sau (li g). Cng t thnh ca mm nguyn thy chi ra 5 n: - Mt n ng dc t gia n trn r xung (tc vch ngn mi sau ny). - Hai n ngang trc gi l n khu ci, t hai n hm trn hai bn tin ra ng gia t gn lin vi nhau, to thnh vm ming cng. - Hai n ngang sau cn gi l n chn bm khu ci, cng xut pht t n hm trn 2 bn, tin ra ng gia gn dnh vi nhau, to thnh vm ming mm v li g.

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B sau ca 2 n ngang trc gn dnh vi b trc ca 2 n ngang sau, to thnh s lin tc ca vm ming. Nu v mt nguyn nhn no (ni ti hoc ngoi lai) tc ng vo, lm ngng tr qu trnh pht trin v gn dnh ca cc n mt, s dn n cc khe h d tt bm sinh hm mt tng ng. T thuyt trn ta c th c nhng loi khe h sau: - Khe h mi bn hm trn: n hm trn khng dnh n mi trong - Khe h mi gia hm trn: 2 n khng dnh nhau - Khe h cho mt: n mi ngoi khng dnh n hm trn - Khe h ngang mt: n hm trn khng dnh n hm di - Khe h mi di: 2 n hm di khng dnh nhau - Khe h vm ming cng: 2 n ngang trc khng dnh - Khe h vm ming mm: 2 n ngang sau khng dnh Lu : - C th khe h mi m khng c khe h hm, nhng ngc li th khng th - C th c khe h vm ming mm m khng c khe h vm ming cng, nhng ngc li th khng th. Vch ngn mi

ng vm ming cng S h xung ca li

Hnh 8.2: S hnh thnh ca vm ming th pht (Formation du palais secondaire) [26]

2.3. Nguyn nhn C hai loi nguyn nhn: ngoi lai v ni ti Theo Dimitrieva (1964) lit k nguyn nhn sinh bnh nh sau : 2.3.1. Nguyn nhn ngoi lai - Yu t l hc: c hc, nhit, phng x - Yu t ha hc: thiu oxy, suy dinh dng, ri lon ni tit, nhim cht c (Teratogen) - Yu t sinh vt: virus, vi khun v c t, k sinh trng. - Yu t thn kinh 2.3.2. Nguyn nhn ni ti - Yu t di truyn - S khng han chnh v mt sinh vt ca t bo sinh dc - nh hng ca tui v ni ging Theo Rosenthal, nguyn nhn ngoi lai chim 70% trng hp (k c nhng yu t khng bit), cn 30% l nhng yu t ni ti.

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Trn Rnh khu Tri Phi Mi Khe OMM MN MN Khe OMM Khe gia

Hm trn MT MT

Hm trn

Hm di

Hm di S 8.1: S hnh thnh vm ming s pht

Vit nam, theo khoa Rng Hm Mt bnh vin Vit c nm 1971 vn sc khe ca ngi m chim t l cao 71,4%. Trong b cm chim 67,1% Gabka phn tch trn 2500 bnh nhn khe h mi v khe h vm ming thy: - Khng thy nguyn nhn : 23,2% - Di truyn : 15,1% - Hong s chung : 10,9% - M trn 40 tui : 6,7% - Hay chy mu khi mang thai : 5,1% - Nhim c rau thai : 6,7% - Mc bnh do virus thi k mang thai : 3,4%

3. LM SNG
3.1. Phn tch v phn loi - Phi tnh: n t hn nam, theo Rosenthal, t l 2/3 (n/nam). Vit nam (Bnh vin Vit c) trong 1477 trng hp nam chim 56,5%, n chim 43,5%. - Pha khe h: bn tri nhiu hn bn phi (gp 2,5 ln) - ln ca khe h: hin nay thng dng danh t ton b v khng ton b, ch ln ca khe h mi v vm ming. Nm 1964, Bethman v nm 1966, Burian c s dng li chia : 1, 2, 3. Trong , 1 v 2: khng ton b; 3: ton b 3.2. Cc loi khe h bm sinh vng hm mt Theo Kernahan v Stark (M 1958) c bn loi ln trong cc khe h bm sinh hm mt. im c bn ca phn loi ny l ph hp vi bo thai hc, ly l khu ci trc lm ranh gii, phn trc l vm ming tin pht (nguyn pht) gm mi v mu hm, phn sau l vm ming th pht gm vm ming cng v bum hu (vm ming mm) 3.21. Khe h s pht mi v hm (Cheilo-Gnatho Schisis): - Khe h mi: khe h phn mi v da, khng tn thng phn xng mu hm

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+ Mc nh: mi c khuyt hng ln trn, 1/3 + Mc trung bnh: Khe h lin quan n mi v na phn da ca mi trn, 2/3 + Mc nng: mi trn ton b b chia t mi n hc mi, thng gi l khe h mi ton b, 3/3. Trng hp ny c bin dng cnh mi. - Khe h hm: Phn xng trc l rng ca (l khu ci trc) + Mc nh: vng rng ca bn hm trn c vt hng nh + Mc trung bnh: c khe h vng xng rng + Mc nng: khe h xng n l rng ca 3.2.2. Khe h th pht vm ming cng v bum hu (Urano-Staphylo Schisis) - Khe h bum hu (vm ming mm) + Khe h li g + Khe h li g v 1/3 gia vm ming mm + Khe h vm ming mm ton b - Khe h vm ming cng: + Khe h n 1/3 sau + Khe h n 1/3 gia + Khe h vm ming n l rng ca 3.2.3. Khe h phi hp mi v vm ming 3.2.4 Khe h c bit khc t thy trn mt: khe h mi trn gia, khe h mi di, khe h ngang mt, khe h cho mt. TRI Mi (Cheilo) PHI Khe h s pht Mi hm (Cheilo-Gnatho Schisis) L rng ca ( L khu ci trc) HE cng (Urano) Khe h th pht Vm ming - Bum hu (Urano- Staphylo Schisis)

Hm (Gnatho)

HE mm (Staphylo)

S 8.2: Phn loi khe h mi v vm ming theo Kernahan v Stark (M, 1958)

3.3. Chn on chn an y v ng cn phn tch v nh gi nhng yu t sau: - Pha bn ca khe h: Mt bn (phi hoc tri), c hai bn. C khi ngi ta cn gi l n hoc kp - Mc nhiu hay t ca khe h: Khng ton b, ton b, hoc 1, 2, 3 - S b nu c mt nguyn nhn c kh nng nht.

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Th d, Khe h mi tan b nghi do virus cm; khe h mi mt hai bn nghi do yu t di truyn...

4. IU TR
4.1. Nguyn tc c bn ca iu tr khe h mi v vm ming Trong vic iu tr cc bnh nhn khe h bm sinh hm mt, phi phi hp nhiu chuyn khoa. Do , ngy nay c danh t Phc hp iu tr bnh nhn. Trong ch cch thc iu tr, thi gian iu tr v s dng nhng kin thc khoa hc hin i nht, phc hp iu tr gm: 4.1.1. Thi gian iu tr thch hp Vic iu tr phc hp ny ko di t khi mi sinh, n tui trng thnh 20 - 25 tui, vic iu tr phu thut c th can thip vo lc vi thng tui, n 1- 2 tui i vi khe h mi v 2 - 5,6 tui i vi khe h vm ming. Tuy nhin, thi gian ny cn ty thuc vo tng trng hp lm sng v th a ca bnh nhn 4.1.2. iu tr chnh hnh C ngha l sn sc v iu chnh mang li khp cn bnh thng, qua cc giai on pht trin xng hm. iu tr ny cn c tc dng lm thay i 1phn v mt v ting ni ca bnh nhn. 4.1.3. iu tr pht m L cng vic kh khn v phc tp, bt u t lc bit ni, trc lc iu tr phu thut. Sau iu tr phu thut cn thit phi tip tc iu tr pht m cho n tui trng thnh 4.1.4. iu tr phu thut Ch yu l cc phng php m to hnh mi v vm ming. Theo thi gian, phng php m khe h mi v vm ming ngy cng pht trin v hin nay cc phng php m c ci tin hon chnh nh phng php Millard, Tennison, Barsky. Vi cc phng php ny c th em li cho bnh nhn mt v thm m kh hon ho, trnh c phn no s mc cm v d tt ca ngi bnh i vi x hi 4.2. Gii thiu cc phng php phu thut to hnh mi 4.2.1. Nguyn tc - Lp kn c khe h - C hnh thi bnh thng v nhn trung, ranh gii da v ln mi ; cung Cupidon, hnh dng cnh mi. 4.2.2. Cc phng php m - To hnh bng cch khu gip n thun cc b khe h nh phng phpVeau, Rosenthal, Husson - Rose... - To hnh bng cch khu gip phc hp cc b khe h (to hnh ch Z) theo phng php Tennison, Millard...

5. D PHNG
Khe h d tt bm sinh vng hm mt l mt d tt kh ph bin, m nguyn nhn rt kh xc nh c th, y l loi d tt bm sinh lm nh hng nhiu n thm m, tm l v chc nng pht m, n ung, lm cho ngi b d tt lun lun c mc cm vi mi ngi trong x hi. Vic iu tr cng rt phc tp, tn km v khng c hon ton nh . V vy, vic d phng lm gim t l d tt l rt ng quan tm, c bit l vic gio dc v khuyn co cho ph n tui sinh con, cn lu nhng yu t c nguy c gy d tt nh vn : tui sinh con, ngh nghip, mi trng sng, tnh trng dinh dng lc mang thai, tnh trng tm l... Vic iu tr, chm sc sm v ng cch cc d tt bm sinh hm mt, cng gp phn trong vic d phng nhng ri lon nng thm ca d tt. C th:

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5.1. D phng cp 0 - Nh nc cn c nhng chng trnh lm sch li mi trng, c bit l nhng vng dn c nhim thuc khai quang trong chin tranh - Quan tm n ch bo h lao ng, trnh tai nn lao ng, trnh nhng cht c trong nh my cng xng sn xut, ch v cc cht phng x v nhit - Vn ng nhn dn thc hin tt lut hn nhn v tui sinh con hp l - T chc v vn ng cc hi on trong x hi, cng vi ngnh y t gip v vt cht, tinh thn v iu tr sm, ng cch cho ngi b d tt bm sinh hm mt 5.2. D phng cp 1 Tuyn truyn v gio dc cho ph n tui sinh con c thc phng, trnh nhng yu t nguy c c th dn n d tt bm sinh hm mt cho thai nhi: vn tui sinh con, dinh dng trong lc mang thai, tnh trng tm l, sang chn c hc, an ton trong lao ng... 5.3. D phng cp 2 - Hng dn cho ngi m c con b d tt bm sinh hm mt bit cch cho b, n trnh sc, quan tm n dinh dng cho chu nh. - iu tr kp thi v ng cch cc trng hp d tt bm sinh hm mt, phc hi c phn no v thm m v chc nng cho ngi b d tt, trnh c phn no mc cm tm l cho ngi bnh v thn nhn. 5.4. D phng cp 3 - M li cc trng hp c so xu, thiu chiu rng, chiu cao ca mi em li thm m hon thin hn cho ngi bnh - Dy pht m ng sau cc trng hp phu thut mi v vm ming./.

CU HI T LNG GI
Cu 1: T l DTBS hm mt trung bnh trn th gii l A. 1% D. 15 B. 1 E. 20 C. 10% Cu 2: Trong cc bnh virus, bnh no c kh nng gy d tt bm sinh cao nht: A. Si B. Thu u C. Cm D. St xut huyt E. Vim gan B Cu 3: Khe h DTBS hm mt thng gp nht l: A. Khe h mi bn hm trn B. Khe h mi di C. Khe h mi gia D. Khe h cho mt E. Khe h ngang mt Cu 4: Khe h vng mt no sau y him gp: A. Khe h mi trn B. Khe h hm ch mm C. Khe h mi di D. Khe h hm ch cng E. Khe h phi hp mi- hm ch

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Cu 5: Theo Rosenthal, t l DTBS hm mt gia N v nam (n/nam) l: A. 1/3 B. 2/3 C. 3/3 D. 4/3 E. 5/3 Cu 6: Chn on khe h mi ton b hai bn, c ngha l c 2 bn u b tn thng: A. Mi B. Mi v mt phn da C. Mi v c phn da n hc mi D. Mi da n hc mi v c xng rng E. Mi , phn da n hc mi v c xng rng Cu 7: Cc phng php iu tr cc khe h mi - hm ch bao gm: A. Chnh hnh xng hm, rng B. Dy pht m C. Chm sc v nui dng D. Phu thut E. Tt c ng Cu 8. Theo thuyt "N mm", khe h mi bn hm trn l do thiu s rp ni gia hai n mi trong. A. ng B. Sai Cu 9. Trong thc t lm sng, nu c khe h cung rng th lun km theo khe h mi. A. ng B. Sai Cu 10. Phu thut khe h hm ch l mt phu thut phc tp, chy nhiu mu, hu phu kh khn. V vy, tt nht nn phu thut lc 15 tui tr ln. A. ng B. Sai

TI LIU C THM
1. Trn Thu Nga (2001), Nha Khoa Tr Em, NXB Y Hc TP.HCM. 2. B Mn RHM i Hc Y H Ni (1979), Rng Hm Mt Tp 1, 2, 3, NXB Y Hc

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Chng 9

CC KHI U LNH TNH HAY GP VNG MING - HM MT

Mc tiu hc tp
1. Trnh by c triu chng cc khi u lnh tnh hay gp vng ming - hm mt. 2. Phn bit c vi khi u c tnh. 3. Chuyn bnh nhn kp thi n cc tuyn c chuyn khoa phu thut hm mt.

1. I CNG
Vng ming - hm mt c th c cc u lnh tnh nh u mch mu, u xng v.v v cc u lnh tnh c hiu khc nh u li, u nguyn bo men (ch c xng hm), u hn hp tuyn nc bt.

2. CC KHI U LNH TNH

2.1. U mu 2.1.1. Lm sng U mu l u to bi cc mch mu (ng mch, tnh mch, mao mch) tng sinh. C th gp u mu khp ni trn c th nhng vng u, c, mt nhiu hn c (theo J.M Friedman v MB Gormby, 50% trn vng u c mt. Theo Brooklyn 1973, trong cc bnh v hm mt, u mu l loi u lnh hay gp nht, chim khong 10 - 15 % cc trng hp phu thut). C nhiu loi u khc nhau, nhng c chung mt s triu chng lm sng nh: - Mu hay mu tm. - Ni g trn da hay nim mc, nu ta bp hay n u th u xp, bung tay ra u li phng tr li. - U khng au. - Nu va chm xy xt c th gy chy mu. - Khi xy xt, c th nhim trng ph v lm chy mu nhiu gy nguy him. Cn c vo gii phu bnh l v du hiu lm sng ta c th gp vi th u mu sau y: - U mu phng (angiome plan): l nhng bt trn da mt, a s bm sinh hay c t lc nh, tuy khng c g nguy him nhng nh hng n thm m. Khi n tay vo u rt i thnh mu trng, bung tay u li tm. - U mu g (angiome tubreux): g trn da tng chm nh chm du. - U mu di da: thng to thnh cc hang mu, ch yu do tnh mch tr thnh x, hang (caverneuse). S ng mu lu ngy to thnh cc ht si trng. S u hi chc, thy r cc ht sn cng rn. Chp X quang thy r cc ht sn. Chn on: Da vo mu sc, s bp u xp, c th chc ht ra mu. 2.1.2. iu tr - U mu phng c th c ct, ghp da hay dng phng php p lnh bng nit lng - U mu g, u mu di da cng c th phu thut ct b nu u nh, c ranh gii r. Nu u to, ranh gii khng r nguy him nu phu thut, ta c th tim gy x bng thuc tim x. - Vit Nam hay dng huyt thanh mn u trng un nng ln 70 - 80C v tim vo khi u. U mu cng c th iu tr bng tia x.

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2.2. U bch mch t gp hn u mu (khong 1/3 nu tnh chung vi u mu). 2.2.1. Lm sng C th gp li, m (da v nim mc), mt v vng di hm, bn c, khc vi u mu, u bch mch mu sc da v nim mc trn u gn bnh thng. - U bp khng xp. - U bch mch d b nhim trng ph. - Th bnh hay gp nht l u bch mch nang (kystique) gp vng di hm, cnh c tr s sinh, vi thng tui. - U pht trin nhanh, khng nn chc ht gy nhim trng. 2.2.2. Chn on U s mm, lng bng, bp khng xp, mu sc da v nim mc trn u gn nh bnh thng. 2.2.3. iu tr C th tim gy x hay phu thut ct b u. 2.3. U xng C th l nguyn pht (t t bo to xng) hay th pht (t t bo to sn hay to x) u pht trin chm (hng nm) lm mt cn i mt. - Chp phim X quang thy xng ni u m c. - Ch m u xng theo li o gt bt u theo yu cu thm m. 2.4. U li rng U c lin quan v bnh sinh mt thit vi s thay i kch t n tui thiu nin v ph n mang thai. 2.4.1. Lm sng c ba th bnh - U li x: mt nhn, mt u u, xng bnh thng. - U li si: mu sm, si, s mm, hay chy mu, u pht trin t li k hai rng, trn phim X quang thy c du hiu tiu xng gia hai huyt rng. Thng gp trn ph n c thai, thng sau khi u t bin i. - U li th ht: mm mu sm. 2.4.2. Chn on u li d da vo hnh th v v tr u. 2.4.3. iu tr Phu thut ct b u v c khi phi nh rng v bm b phn xng m u xm ln. 2.5. U lin bo men 2.5.1. Lm sng Pht trin t t bo to men rng hnh sao (amloblastome). 2.5.2. Gii phu bnh l u C th c s kt hp cc t bo khc lm thnh nm th bnh: - U nguyn bo men th nang + Bnh nhn tui thanh nin hay trung nin. + Thng gp ngnh ngang xng hm di. + U pht trin dn ngy cng to lm bin dng mt. + S u c triu chng bng nha (bp u thy nh bp qu bng nha, bng bn - xp mt vt lm, nu bp nh di tay thy phng tr li.

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+ Rng trn u lung lay. + Phim X. quang: hnh nh nhiu nang. + Chc ht ra dch vng c ht cholesterin - U x nguyn bo men: c thm t bo x, u pht trin chm. - U men tuyn (adno - amloblastome) hay gp hm di vng rng nanh. - U rng x tuyn bo men (fibro - odonto - amloblastome). - U rng nguyn bo men (odonto - amloblastome) hay u men c. Phim X. quang l mt khi cn quang c hnh nhiu rng dnh vo nhau. Chn on u nguyn bo men da vo triu chng lm sng v phim X. quang. 2.5.3. iu tr Phu thut no, hay ct b u cng vi mt phn xng lnh. U nguyn bo men d ti pht sau m. C mt s ca rt nh tr thnh u c tnh. 2.6. U hn hp tuyn nc bt U do s pht trin ca lin bo ti tuyn v ng tit vi cc t chc lin kt m, i khi c c sn. Rt hay gp, chim 50 % trong s cc u tuyn mang tai. 2.6.1. Lm sng U hn hp tuyn mang tai pht trin ko di tri qua ba giai on: 2.6.1.1. Giai on u: ko di vi nm. - Triu chng chc nng: khng. - Triu chng thc th: + U trn nh khong 1cm. + Chc u, di ng d l ng stnon bnh thng. + Khng c hch. 2.6.1.2. Giai on ton pht: bnh nhn trung nin (40 - 50 tui). - Triu chng chc nng: + U thy r, mt cn i mt. + Khng au, khng nh hng ti sc khe. - Triu chng thc th: + Nhn: u to bng nm tay vng mang tai (nu l u tuyn di hm th nh hn) da cng, c ch g cao, mu sc da bnh thng. + S: u c ch rn, ch mm, ranh gii r, u nng, di ng c. 2.6.1.3. Giai on thoi ha c tnh - Triu chng chc nng: au v lit mt. - Triu chng thc th: u rt to, da lot, u dnh vi t chc xung quanh. - Vi u ny nu chp X quang sau khi bm thuc cn quang (sialographie) vo tuyn qua l tit, u tuyn mang tai c hnh mt bn tay (l cc ng tit) m qu bng (l u). 2.6.2. iu tr - Cn m sm trnh tai bin lit mt. Nu thai ha th m ct rng, chu lit mt v phi iu tr tia x, hay ha tr liu sau m. - Chn on phn bit cc u lnh k trn vi ung th phn mm hay phn xng.

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- Cc u lnh khng au (tr khi c nhim trng km theo) khng c hch, thi gian tin trin ko di, khng hoc rt t nh hng n sc khe v cc b phn gii phu ln cn./.

CU HI T LNG GI
Cu 1. U mu phng l: A. Nhng u mu ni trn mt da B. n vo khng i thnh mu trng C. a s xut hin khi ln tui D. L nhng bt trn mt da E. Khng nh hng n thm m. Cu 2. U mu g: A. L nhng bt trn mt da B. n vo khng xp C. S khng c mch p D. G trn da tng chm nh chm du E. Khng nh hng n thm m Cu 3. U mu di da: A. Ch yu do tnh mch tr thnh x, hang B. Khng c s nh mu C. Khng to thnh si D. U rn chc E. Khng c cc ht sn cng Cu 4. U bch mch: A. Gp nhiu hn u mu B. Thng gp da C. Thng gp da v nim mc D. Thng gp vng m E. t b nhim trng Cu 5. U li rng thng c cc biu hin sau: A. U li x B. U li hu ct bo C. Khng lin quan n s thay i kch t n D. X quang khng thy du hiu tiu xng. E. t gp ph n c thai. Cu 6. U men c to rng thng xy ra la tui sau: A. Mc rng sa B. Mc rng vnh vin C. Bm sinh D. Sau 20 tui E. Tui gi. Cu 7. U men th nang tin trin c c tnh no sau y: A. Pht trin c gii hn B. Pht trin khng gii hn C. Khng t thoi ha c tnh D. Kh ti pht nu ct b khng ht. E. Khng cho di cn xa khi c thoi ha

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Cu 8. U men c l mt khi u cng trong : A. Ton l cc rng d dng. B. Ton l t chc men rng. C. Ton l t chc men v ng. D. Ton l t chc men, ng v cc rng d dng. E. Ton l t chc ng rng. Cu 9. iu tr u men th nang phi: A. Nh rng v dn lu dch nang. B. Nh rng v no vt t chc nang. C. Phu thut no vt t chc nang v men D. Phu thut ct b rng ra xung quanh khi u. E. Phu thut ct b rng v no cc hch nghi ng. Cu 10. U hn hp tuyn nc bt c tnh cht sau: A. Rt t gp B. Chim 50% trong s cc u tuyn mang tai C. Chim 70% trong s cc u tuyn mang tai D. Chim 90% trong s cc u tuyn mang tai E. Khng phi do s pht trin ca lin bo ti tuyn v ng tit vi cc t chc lin kt m, i khi c c sn.

TI LIU C THM
1. L Hng Lin (2003), Gio Trnh Nh Rng Tiu Phu, B mn RHM Trng H Y Hu 2. Trn Vn Trng (2001), U Lnh Tnh Vng Mt, NXB Y Hc.

79

Chng 10

UNG TH NIM MC MING

Mc tiu hc tp
1. Trnh by c cc tn thng sm ca ung th nim mc ming. 2. Lm c cc xt nghim n gin i vi mt tn thng nghi ng c tnh. 3. Chn on c ung th nim mc ming.

1. I CNG
- Ung th (K) vng hm mt thuc nhm ung nh u v c Theo phn loi ung th trn c th ngi ca Hi chng ung th th gii nm1970 Houston, K vng hm mt bao gm: K nim mc ming, K xng hm, K tuyn nc bt, K da, K ca t chc to mu. Trong K nim mc m l hay gp nht. - K nim mc ming l mt tn thng l ra ngoi nn d nhn thy, d chn on v iu tr. - K nim mc ming l mt tn thng nm phn trn ca c quan tiu ha., d sang chn to thnh vng xon bnh l lm cho tn thng pht trin nhanh: tn thng lot v sang chn gy chy mu, nhim trng v lot. C th ni rng ung th nim mc ming lun gn lin vi chy mu v nhim trng. - K nim mc ming lin quan mt thit vi cc c quan ln cn nh xoang hm, mi, mt, thn kinh. - K nim mc ming thng l K biu m Hay gp ngi trung tui, tin trin tng i chm so vi cc ung th khc nh sacm hoc K ca t chc to mu. - K nim mc ming giai on u triu chng ngho nn, bnh nhn thng n mun giai on T3, T4 rt kh khn cho iu tr v tin lng. - K nim mc ming thng chn on d da vo lm sng v t bo hc ... kt qu iu tr ty thuc tng bnh nhn, ty giai on, v loi t bo K. - Gii phu bnh l K nim mc ming ch yu l ung th biu m t bo gai (90 %). Xp loi gii phu bnh l ung th theo h thng TNM ca T chc quc t chng ung th (UICC), gm: + T (Tumor - khi u) T0: Khng c triu chng lm sng v X quang pht hin ung th. T1: U khu tr nng, kch thc di 2 cm T2: Kch thc u trn 2 cm m khng c thm nhim xung quanh. T3: Kch thc u trn 3- 4 cm c thm nhim da v t vng ln cn. T4: U ln, xm nhp cc b phn ln cn.

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+ N (Node - hch vng) N0: khng pht hin c hch. N1: hch nh di ng cng bn N2: hch nh di ng 2 bn N3: hch to dnh + M (Metastasis - di cn xa ) M0: khng pht hin c di cn M1: c di cn xa Nu lm gii phu bnh l hch thy t bo ung th ghi thm N+

2. DCH T HC
Vit Nam, K nim mc ming chim khong 1,7 % tng s cc loi K, nu tnh c ung th li v mi t l l 3,7 % (theo s liu ca Vin K H Ni, t nm 1967-1971); theo s liu ca Nguyn Vn Th t 1957-1975, K nim mc ming chim 18 %. nc ngoi: M 1968, K vng ming chim 2,5 %, Vin Roussy Php 1957: ung th ming chim 10 %. V gii phu bnh l: Vit Nam, K biu m chim 78,4 %; Php, K biu m chim 95% (Frank).

3. NGUYN NHN GY UNG TH

- Nguyn nhn do ha cht nh sn phm cacbua, nm mc, thuc l, thuc tr su. - Nguyn nhn vt l nh tia X, phng x, tia cc tm. - Di truyn. - Virus nh Epstein Barr (EBV 1964) gy u lympho Burkitt v u vm. - Yu t a l, tp qun, sc khng ca c th.

4. TRIU CHNG
4.1. Chc nng au vng tn thng, au ngy cng tng. n, ni kh khn, chy mu t nhin hoc sau sang chn. Rng lung lay ngy cng tng. Hi chng tai mi hng: ngt tc mi, chy mu mi; to, dy mi trn v au nhc vng xoang. Triu chng ny thng xuyn xy ra mt bn. Hi chng mt: au nhc mt, li mt, tc l o, lit, lc nhn cu. 4.2. Thc th 4.2.1. Giai on sm - Th lot: vt lot nng, mm nim mc, hoc li quanh rng, vt lot pht trin rng v su xung xng hm, vt lot c y c ph mt lp gi mc hoc t chc hoi t, b nham nh, chm vo d chy mu. - Th si: t chc si nh hoa sup l, dnh cht y, km theo lot hoi t, chm vo d chy mu. - Th lot si: thng gp cc v tr sau:

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+ mi: ng vin da v nim mc. + nim mc m: gia tng ng cung rng, sau rng s 8. + sn ming - hai bn rnh li. + Li: b bn 2/3 trc v 1/3 sau. + Vm ming: b bn, bum hu. 4.2.2. Giai on mun Tn thng nim mc lan ra t chc ln cn nh xng hm, xoang hm, h chn bm hm. Tn thng xng hm, u lan ra ph hy xng to u xng hm, ranh gii khng r, thm nhim da, hn ch h ming, ngch li phng, si lot, rng lung lay, ming hi thi, t chc si lot d chy mu. Tn thng xoang hm, ngt tc mi, au nhc vng xoang mt bn, sp hm ch, mt trc xng hm trn phng c th thm nhim da. Khm thnh bn mi b y vo trong, c th c t chc si qua l thng ngch mi gia.Tn thng xoang hm c th lan ln mt gy cc triu chng mt, rng lung lay. 4.2.3. Di cn hch Hch di hm, di ng hoc dnh l ni hay di cn nht. Hch cnh c dc theo b trc c c n chm v hch thng n. 4.3. Triu chng cn lm sng 4.3.1. Nghim php xanh toluidin p dng cho nhng tn thng nghi ng c tnh. Tin hnh: bi acid acetic 1% sau bi xanh toluidin 1% ch 10 giy n 1 pht ra li bng acid acetic 1%, kt qu m c tn thng bt mu xanh. u im: xt nghim n gin, dng pht hin sm K nim mc ming. Nhc im: mt s tn thng vim cng bt mu xanh. 4.3.2. Xt nghim t bo b mt Xt nghim ny rt quan trng i vi vic chn on sm K nim mc ming. C s ca phng php ny l nhng t bo trc ra t khi u c cng tnh cht vi t bo u ly bng phng php sinh thit. u im: n gin, kt qu sm, lm nhiu v tr mt lc, hng cho sinh thit ng v tr, t l cao 90 %. Nhc im: khng xt nghim c tn thng su hoc ly phi t bo vim b mt, mun c kt qu chnh xc phi lm sinh thit. Tin hnh: gt b mt tn thng bng cy li no ly t bo lp di, qut t bo no c ln phin knh - c nh bng cn 90 , gi gii phu bnh. 4.3.3. Phu thut sinh thit Phu thut sinh thit nhm chn on xc nh ung th, trc hoc sau khi iu tr, ty theo tn thng nng hoc su c th lm ngay trn gh khm hoc trong phng m. Bnh phm sinh thit yu cu rng 1 cm x 0,5 cm, tt nht l ly gia ranh gii t chc lnh v t chc ung th.

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Bnh phm c ngm vo cn 90 c nh v gi chuyn khoa gii phu bnh. 4.3.4. X quang Ty tng bnh nhn chn cc t th chp phim: phim rng, t th mt thng, hm di chch, Blondeau, Hirtz, Chp Scaner (ct lp). 4.3.5. Cc xt nghim cn thit cho c quan nghi ng c di cn. 4.3.6. Cc xt nghim thng thng: v mu, X quang tim phi v.v... nh gi ton trng ca bnh nhn.

5. CHN ON
Da vo kt qu lm sng, X quang, t bo hc cn phi xc nh: - V tr, kch thc u. - T chc b xm ln. - T bo ung th loi no. - Xp loi theo TNM. - Xp theo giai on.

6. IU TR
Ty theo tng bnh nhn, giai on no, K loi t bo g m la chn cc phng php thch hp. 6.1. Phng php phu thut L phng php iu tr tt nht, nguyn tc l - Phu thut rng, ct b ton b u v t chc ln cn b xm ln. - Phu thut no vt hch, ct b ht hch di hm, hch dc c c n chm. - Phu thut sm kt qu sng trn 5 nm hn 50 %. 6.2. Phng php tia x Tia x c tc dng tt vi ung th t chc lin kt v ung th biu m t bit ha, hay ti pht, i vi ung th biu m tia t tc dng, thng ch p dng nhng bnh nhn khng phu thut c hoc phu thut khng trit , c 3 loi tia sau: X, tia in t, tia radium. Tia iu tr c th gy lot da, hoc tiu xng, bch cu gim, hng cu gim. V vy, iu tr tia phi theo di st v chn phng php iu tr thch hp. 6.3. Phng php ha tr liu Ha tr liu c nhc im l gy tn thng c t bo lnh. Gy gim bch cu, vim ti mt, rng tc v.v... Ha tr liu c dng trong nhng trng hp: trc m thu nh u, khng phu thut c, phu thut khng trit , dng ha tr liu c 3 ng: ung, ng mch, tnh mch. Hin nay, cc loi thuc thng dng l: Cyclophosphamid (Endoxan), Triethyleaminobenzochinon (Trenion). 6.4. iu tr min dch Nguyn tc: lm tng sinh sn t bo lympho T, tng kh nng min dch c th. Ha cht: LH1, Eshlem, v BCG.

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6.5. Phu thut lnh Nguyn tc dng nhit thp dit t bo K. Dng Ni t lng 196 C. Kt qu tt i vi ung th da, hoc K khng cn kh nng phu thut.

7. TIN LNG
Tin lng ph thuc vo: - Giai on sm hay mun. - Loi t bo K. - Phng php iu tr. - Sc khng ca c th. pht hin sm: trc mt tn thng nghi ngh c tnh cn phi lm ngay cc xt nghim cn thit chn on. Trn th gii K vng ming hm mt iu tr sng trn 5 nm l 35 %

CU HI T LNG GI
Cu 1. K nim mc l mt tn thng: A. L ra bn ngoi nn d nhn thy B. Chm trong t chc kh nhn thy C. Khng lin quan n c quan tiu ha D. Khng lin quan n c quan ln cn E. Khng di cn Cu 2. Xt nghim dng pht hin sm ung th nim mc ming l: A. Chp X quang D. Phu thut sinh thit B. Xt nghim t bo b mt E. Siu m. C. Nghim php xanh Toluidin Cu 3. K nim mc thng di cn vo hch no nht: A. Hch thng n B. Hch c C. Hch di hm D. Hch b trc c c n chm E. Hch di li. Cu 4. Triu chng chc nng ca K nim mc: A. au vng tn thng, au gim dn B. au vng tn thng, au tng dn C. Khng au D. Khng nh hng n n, ni E. Khng chy mu t nhin Cu 5. Triu chng thc th ca K nim mc giai on sm th lot: A. Vt lot cng nim mc B. Vt lot khng n su xung di C. Vt lot pht trin rng v n su xung di hm d chy mu D. Vt lot khng c y E. Vt lot khng chy mu

84

Cu 6. Tnh cht ca th si trong bnh ung th nim mc ming l mt: A. T chc si nh hoa sp l, khng dnh y B. T chc si nh hoa sp l, khng km lot C. T chc si nh hoa sp l, khng d chy mu D. T chc si nh hoa sp l, dnh cht y E. T chc si nh hoa sp l, dnh cht y, d chy mu Cu 7. Th lot si thng gp cc v tr sau: A. mi, nim mc mi trn. B. nim mc m: trc rng s 8 . C. sng ming, sau rnh li D. li, b bn 2/3 trc v 1/3 sau E. vm ming, ch yu l hm ch mm Cu 8. iu tr K nim mc phng php tt nht l: A. Khng sinh, chng vim B. Tia x C. Ha tr liu D. Phu thut E. iu tr min dch Cu 9. Xt nghim t bo b mt chn on sm K nim mc l: A. Ly lp su ca tn thng. B. Ly ranh gii tn thng. C. Ly lp di ca tn thng. D. Ly b mt ca tn thng E. Ly c t chc lnh v bnh l. Cu 10. Phu thut lm sinh thit K nim mc, bnh phm ly c phi: A. Nh hn 0.5 cm B. Rng 1cm x 0.5 cm C. Ly chnh gia tn thng D. Ly b mt tn thng E. Ly ngoi tn thng. TI LIU C THM 1. Trn Vn Qu (2005), Gio Trnh Phu Thut Hm Mt, Khoa RHM Trng H Y Hu 2. Trn Vn Trng (2002), U c Tnh Vng Ming-Hm Mt, NXB Y Hc.

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Chng 11

CHM SC RNG MING BAN U

Mc tiu hc tp
1. Trnh by c nh ngha v ngha ca chm sc rng ming ban u. 2. Lit k c cc ni dung chm sc rng ming ban u. 3. Phi hp t chc c cc hot ng chm sc rng ming ti c s. Bnh rng ming l bnh ph bin nc ta, t l mc bnh kh cao. Theo iu tra sc kho rng ming ca ton quc nm 2000, t l su rng sa ca tr t 6 - 8 tui l 85%, t l su rng vnh vin ca tr 12 - 14 tui l 64%, 15 - 17 tui l 68,6%, t l vim nu ca thanh nin t 15 - 17 tui 93,53%, t l vim nha chu ca ngi trn 45 tui l 98,95% .V vy, chng ta khng th dng bin php c nhn, c th l khng th ch c bc s khm v cha rng, ly cao cho bnh nhn b au rng v vim li (nu)... khng th ch gii quyt bng cch o to cn b, trang b my mc dng c nha khoa... c th lm gim t l bnh, m cn phi dng bin php y t cng cng gii quyt bnh rng ming. Song song vi vic iu tr rng ming v lm rng gi, chng ta cn y mnh cc bin php phng bnh rng ming, m chm sc sc kho rng ming ban u l mt khi nim mang tnh phng bnh v l mt bin php y t cng ng, p ng c yu cu ca cng ng, em li sc kho cho ton dn vi ngun ti chnh gii hn ng thi c th thc hin mi mc x hi (, ang v km pht trin). C lm c cng tc chm sc rng ming ban u chng ta mi mong gii quyt mt cch c bn, ng n vn rng ming t nay v sau. 1. NH NGHA Chm sc rng ming ban u (CSRMB) l s nh bnh v d phng cc bnh rng ming, s dng cc k thut ti ch c sn t cn bn trn s hp tc ton din v s tham gia ca cng ng, d phng vn rng ming khn cp trong cng ng, nhm vo vic gim au v duy tr sc kho rng ming tt. Chm sc sc kho rng ming l tm cch, tm phng tin phng bnh, nng cao sc kho c sn v phn u gim s bnh tt, ch khng ch gip cho bnh nhn khi b au. 2. NGUYN TC CA CHM SC RNG MING BAN U 2.1. Phn b hp l Trong cng ng khng bao gi mi ngi c cng mc v sc kho rng ming, thng thng nhng ngi tng lp thp, trnh thp t c iu kin v c hi chm sc sc kho, hoc nhng cng ng mc bnh nhiu v c nhu cu cao cng t c chm sc nht, cho nn chm sc sc kho rng ming ban u l s dng nhn vin chm sc ngay ti ni h ang cng tc v sinh sng, h lm cu ni gia nhn dn vi cc c s khm cha bnh, thay th cc bc s thc hin cc bin php x l nha khoa n gin ng thi h kt hp vi h thng chm sc sc kho chung nn c h tr. V vy, mi ngi u c c hi c phc v sc kho rng ming nh nhau t mc thp n mc cao nht. 2.2. Lin quan n cng ng Cn phi c s tham gia ca cng ng th hot ng chm sc rng ming ban u mi thnh cng, mun th cn phi to lng tin cng ng, phi hiu tp qun ca cng ng v sc kho ni chung v sc kho rng ming ni ring, phi p ng c nhu cu c th ca cng ng...th mi chuyn bin c nhn thc t tng ca cng ng v c s ng h, ng

86

thi phi c s hp tc ca lnh o v cc ban ngnh on th chnh sch, chi ph ph hp cho cng ng. 2.3. Tp trung vo d phng v tng cng sc kho D phng v tng cng sc kho l khi nim ca chm sc sc kho, n khng ch n thun l vt cht (trang b my mc, dng c, thuc men...) m cn v tinh thn (s hiu bit, nim tin...). Tng cng sc kho l mt trong nhng chin lc d phng quan trng cung cp thng tin, cc ch dn, phng php..., nhn dn bit cch x l i vi nhng vn c li hay c hi cho sc kho. 2.4. K thut thch hp Chm sc rng ming ban u s dng k thut thch hp sn c ca a phng cng nhiu cng tt. Th d: trm rng khng sang chn (ART) thch hp cho iu tr su rng giai on sm, chi ph thp, thc hin c mi ni, k thut n gin, c nhn v cng ng c th thanh ton c. Khng cn k thut cao, trang thit b t tin ch phc v cho mt s ngi. 2.5. Phi hp nhiu ngnh Chin lc ci thin sc kho rng ming phi quan tm n ton cng ng v vy lin quan n nhiu ngnh, v s phi hp ca nhiu ngnh mi a n thnh cng. Th d: chng trnh Fluor ho nc my cn s phi hp ca Chnh quyn, cng ngh mi trng, cng ty cp nc, v sinh y t cng ng, ho hc, dinh dng, ti chnh. Chng trnh Nha hc ng cn s phi hp gia hai ngnh gio dc v y t. III. NI DUNG CA CHM SC RNG MING BAN U Da vo 8 ni dung qun l sc kho ton dn v 8 ni dung chm sc sc kho ban u trong tuyn ngn Alma Ata, ngnh RHM ra 8 ni dung chm sc rng ban u Vit Nam: - Gio dc nha khoa bo v rng, li phng bnh su rng, nha chu, ung th. - n ung cn bng v hp l (gim ko dnh, gim n vt). - S dng rng ri Fluor phng bnh su rng. - Dy chi rng cho mu gio, khm v iu tr nh k cho hc sinh ph thng c s (nha hc ng). - Cha bnh thng thng nh su rng, nha chu, cp cu hm mt. - Bo m thuc ti thiu x: thuc cp cu, gim au. - Ci to mi trng nc ung c Fluor. - Khm nh k cho hc sinh v nhn dn pht hin bnh sm. 8 ni dung trn, c thc hin thnh 2 mng li: 3.1. Mng li d phng bnh rng ming L ni dung quan trng nht nhm hn ch ti a bnh rng ming xy ra, cc dch v sc khe rng ming (SKRM) d phng c mc ch loi tr hoc gim thiu bnh rng ming chp nhn c trong cng ng gm: 3.1.1. Fluor ho nc ung ni v khi c th thc hin c kt hp Fluoride ton thn v ti ch. 3.1.2. Trm bt h rnh bng Sealant cho bnh nhn c nguy c 3.1.3. Gio dc sc khe rng ming - Ni dung: nhn mnh vo vai tr ca mng bm trong nguyn nhn cc bnh rng ming, dy v kim sot mng bm, cc thng tin v SKRM, dinh dng, pht hin bnh sm. 87

- Nhn s: s dng nhn vin y t cng ng, o to ngi ti a phng, tp hun cho cc thy c gio cc trng hc... - thc hin mng li d phng, bin php ln hin nay: + Pht trin mng li nha hc ng + Chng trnh Fluor ho phng bnh su rng + Kim sot ch n ung cn bng hp l 3.2. Mng li iu tr khn bnh rng ming - Gim au - Ngn chn nhim trng v chuyn tuyn trn - Cp cu chn thng hm mt Thc hin c 8 ni dung ny cc tuyn c s (trng hc, x, c quan, x nghip...) l thc hin c khu hiu y t gn dn v chm sc c hn 80% dn s. 3.3. Ni dung chm sc rng ming ban u ti Vit Nam 3.3.1. Gio dc SKRM d phng bnh su rng, nha chu v ung th - Nguyn nhn ca cc bnh rng ming, nhn mnh vai tr ca mng bm rng - Cc phng php v sinh rng ming loi tr v kim sot mng bm rng. - Vn dinh dng, ch n i vi bnh rng ming - Triu chng chnh ca cc bng rng ming pht hin bnh sm 3.3.2. Tng cng s dng Fluor mi ni khi c th thc hin c d phng bnh su rng - Fluor ho nc ung (khi nc ni c nng Fluor < 0,7 ppm) - Sc ming vi NaF 0,2% 1tun/1ln - S dng kem nh rng c Fluor - Mui n c Fluor - Ung vin Fluor 3.3.3. Pht trin mng li nha hc ng v dy chi rng cho nh tr, mu gio 3.3.4. iu tr mt s bnh thng thng: su rng (trm rng), vim nu (ly cao) 3.3.5. Lp t thuc ti thiu x: thuc cp cu, gim au 3.3.6. Khm rng nh k v lp h s nha b. 4. CC HNH THC T CHC 4.1. Chng trnh nha hc ng y l chng trnh chm sc sc kho rng ming cho tr em ti trng, trng hc l mi trng tt nht lm cng tc chm sc v a s tr em u i hc, hc sinh nghe li c gio hn ph huynh li c bn b lm gng tt ln nhau. Chng trnh ny c nhiu nc trn th gii thc hin v c hiu qa, cho nn cng tc nha hc ng vi cc ni dung gio dc nha khoa, khm, cha, nh rng v p dng cc bin php d phng, s vn ng phong tro tr em t bo v rng ng thi l tuyn truyn vin tt trong gia nh v bn b. Thc hin c chng trnh ny s thun li hn bnh vin v cc c s y t v thy thuc tm bnh nhn , v uy tn ca thy c gio, v thc tp th, tinh thn thi ua ca hc sinh. Vit Nam hin nay, chng trnh ny c trin khai rng khp v c nhng trng o to cn b lm cng tc ny. 4.2. Chng trnh phng bnh nha chu cng ng Bnh nha chu l bnh nhiu ngi mc trong hu ht cng ng, bnh gy au n, gim chc nng nhai, nh hng quan h x hi v chi ph iu tr tn km.

88

Chm sc sc kho nha chu bao gm d phng, iu tr, sa cha v phc hi, nhm bo tn chc nng v thm m ca hm rng trong sut i sng. Gm 4 loi hnh chm sc: - iu tr khn: kt hp iu tr khn bnh rng ming hay ton thn. - Chm sc mc 1: gio dc cng ng nhm mc ch gia tng kin thc v sc kho nha chu, cung cp thng tin mi ngi t phng nga bnh. - Chm sc mc 2: gm chm sc mc 1 cng vi vic h tr bnh nhn t chm sc, c th ly cao rng trn nu. - Chm sc mc 3: gm mc 1,2, v gii quyt cc vn ca bnh nha chu nh ly cao rng trn nu, di nu, theo di, gim st nh k. - Chm sc mc 4: gm mc 1,2,3 v cc bin php iu tr nha chu phc tp do chuyn vin nha chu ph trch 4.3. Chng trnh phng v pht hin sm ung th vng ming-hm mt Ung th l mt vn thi s hin nay ca y hc hin i, ung th e do tnh mng v gy m nh lo u cho hng triu ngi trn th gii. Ung th ming, hm mt l tn thng d pht hin sm v c kh nng iu tr thnh cng v vy cn t chc chng trnh phng chng ung th bng cc bin php: - Tuyn truyn v gio dc cho cng ng nhng hiu bit v ung th vng ming, hm mt, nhng bin php d phng, theo di pht hin tn thng nghi ng ung th (nhng vt lot nim mc m, mi, li, nhng mng bch sn, u nh...). - Ph bin v t chc cho cc thy thuc tuyn c s nhng bin php v kinh nghim pht hin sm nhng tn thng nghi ng ung th. - X tr sm nhng tn thng c th thoi ho c tnh hoc nhng tn thng tin ung th. 5. IU HNH CHNG TRNH CHM SC RNG BAN U (CSRB) 5.1. Lp k hoch 5.1.1. Thu thp thng tin - Xc nh tnh trng rng ming, nhu cu iu tr khn. - nh gi nng Fluor trong nc ung. - Thu thp cc yu t lin quan: kinh t, x hi, vn ho, i sng, phong tc, tp qun... - Cc iu kin thng tin tuyn truyn. 5.1.2. Chn thnh vin ca cng ng: nn chn ngi ti a phng hun luyn thnh nhn vin sc kho cng ng s phn nh ng tnh hnh ca cng ng 5.1.3. ra mc tiu chnh v mc tiu ph, ni dung v bin php thch hp. 5.2. T chc 5.2.1. Tuyn c s: y t a phng, nhn vin khng chuyn khoa - Khm ban u v gio dc sc kho rng ming. - Phng bnh, iu tr cp cu (gim au...). - Chm sc rng ming ph cp (ly cao, nh rng lung lay...). 5.2.2. Tuyn h tr 1: y t qun, huyn, nhn vin chuyn khoa - Gim st hot ng tuyn c s. - Phng bnh vi k thut cao hn. - iu tr rng ming vi gh my chuyn khoa. 5.2.3. Tuyn h tr 2: bnh vin c chuyn vin RHM. - Qun l chng trnh. - iu tr vi k thut cao hn. 89

5.3. Ngun ti chnh Ngi lp k hoch cn bit: - Ngun ti chnh cho chng trnh l bao nhiu? Ai cp? Ai ti tr?... - Xc nh i tng v vng u tin cn trin khai chng trnh. - Lp qu cho chng trnh. - S dng, chi tiu tin bc hp l v thn trng. - Vn ng ti chnh thm cc nh ho tm, on th. 5.4. Nhng tr ngi cho chng trnh S thc hin bt c mt chng trnh chm sc sc kho no cng c nhng yu t nh hng n s thnh cng hay tht bi, cho nn nhng tr ngi thng gp i vi chng trnh CSRMB l: - Nhn dn cha hiu bit v sc kho rng ming. - nh gi sai tnh hnh rng ming v nhu cu iu tr. - Cng ng khng tham gia. - C s ngn cch gia nhn vin y t v ngi dn. CU HI T LNG GI Cu 1. S dng nhn vin chm sc ngay ti ni h ang cng tc v sinh sng thuc nguyn tc no sau y: A. Lin quan n cng ng D. K thut thch hp B. Phn b hp l E. Phi hp nhiu ngnh C. Tng cng sc khe Cu 2. tng cng sc khe cho cng ng cn: A. Trang b my mc hin i B. Trang b dng c y C. Trang b thuc men y D. Gio dc sc khe rng ming E. To nim tin cho cng ng Cu 3. to lng tin cng ng, chng ta cn phi: A. p ng c nhu cu c th ca cng ng B. Phi hiu thi quen ca cng ng C. Phi nm c m hnh sc khe ca cng ng D. C s hp tc ca lnh o v cc ngnh E. C s ng h ca on th Cu 4.Trong gio dc sc khe rng ming, phng bnh su rng v nha chu, cn nhn mnh iu g? A. Ch n B. Dinh dng C. Triu chng sm ca bnh D. Vai tr ca mng bm rng E. V sinh rng ming Cu 5. Trng hp no sau y nm trong mng li iu tr khn bnh rng ming: A. Trm bt h rnh B. Trm rng su ng C. Ly cao rng D. Cp n thuc E. Gim au 90

Cu 6. thc hin mng li d phng bnh rng ming, bin php ln hin nay: A. Pht trin mng li nha hc ng B. o to gp nhn vin y t cng ng C. Tng cng o to bc s rng hm mt D. Trm bt h rnh E. T chc khm rng nh k Cu 7. Hng dn bnh nhn t chm sc sc khe nha chu cho bn thn thuc loi thuc loi hnh chm sc mc no: A. 1 D. 4 B. 2 E. Khn C. 3 Cu 8. iu hnh chng trnh chm sc rng ban u cn phi lm g trc tin: A. Lp k hoch B. Tm ngun ti tr C. T chc khm iu tra D. Hun luyn nhn vin sc khe cng ng E. nh gi nng fluor Cu 9. T chc tuyn c s nhm chm sc rng ban u gm ni dung no sau y: A. iu tr rng ming vi gh my chuyn khoa B. Ly cao, nh rng lung lay C. Fluor ha nc cng cng D. Trm bt h rnh E. Ly cao, trm rng, nh rng Cu 10. lp k hoch cho chng trnh chm sc rng ban u, ta khng cn thu thp thng tin no sau y: A. iu kin ca trm x B. iu kin thng tin tuyn truyn C. iu kin kinh t, i sng D. Xc nh tnh trng bnh E. Xc nh nhu cu iu tr khn TI LIU C THM 1. Nguyn Toi, Nguyn Thc Qunh Hoa, L Qu Tho (2003), Gio Trnh Nha Cng ng, B mn RHM Trng H Y Hu 2. B Mn Nha Cng ng Khoa Rng Hm Mt i Hc Y Dc TP HCM (1995), Bi Ging Nha Cng ng

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Chng 12

D PHNG BNH RNG MING

Mc tiu hc tp
1. p dng c mt trong cc bin php phng bnh 2. Hng dn v sinh rng ming ng phng php trong iu kin c th.

1. M U
Bnh rng ming, trong ch yu l bnh su rng v vim nu (li) vn l nhng bnh ph bin nht ca nhn loi, y l nhng loi bnh mang tnh dch t. Vit Nam, t l mc bnh cn cao v tng dn theo tui.
Bng 12.1: iu tra c bn sc khe rng ming quc gia nm 1990-2000

TUI 12 15 35-44

SU RNG 57% 60% 72%

VIM NU (LI) 95% 95,6% 99,26%

Trong nhng nm qua, c s quan tm ch o ca B Y t, s phi hp cht ch ca B Gio dc v o to, s hng ng tch cc ca chnh quyn..., nhiu chng trnh chm sc v phng bnh cho cng ng c t ra. Mc tiu phn u n nm 2000-2010 l: - 50% tr 5 - 6 tui khng b su rng sa. - SMT < 2 la tui 12. - 85% ngi 18 tui gi c ton b rng. - 75% ngi 35 - 44 tui cn 20 rng. - 50% s ngi trn 65 tui cn 20 rng. Tuy nhin, sau 10 nm thc hin, qua cuc iu tra sc kho rng ming ton quc ln th 2 vo nm 2000 cho thy su rng la tui 12 duy tr mc tng i n nh (56,6% ; SMT 1,87), nhng la tui 15 v 35 - 44 th t l su rng gia tng (67,6% 15 tui v 83,2% 35 44 tui). T l ngi c bnh nha chu cn rt cao mc 96,7%, trong c 31,8% ngi c ti nha chu nng v su. Mt khc bnh mc rt sm v gp mi gii, mi la tui, ngh nghip, trnh vn ha, tng lp x hi, dn tc, mi vng a l khc nhau . Ngoi ra bnh cn nh hng n nng sut lao ng, kinh t (quc gia, c nhn), cn dn n nhng bin chng nh hng n sc khe ton thn v thm m. D phng bnh rng ming l mt ni dung ca chng trnh chm sc rng ban u nhm em li sc khe rng ming cho mi ngi vi ngun ti chnh gii hn, cho nn trong iu kin kinh t x hi nc ta, trang thit b v cn b chuyn khoa cn hn ch th chin lc y t quc gia c t trn nn tng d phng, nhm h thp t l bnh rng ming v t c mc tiu ra n nm 2010, gim t l bnh rng ming trn 50%.

2. CC BIN PHP PHNG BNH RNG MING

Mun phng bnh rng ming c hiu qu th phi bit chn bin php thch hp. u tin l lm cho nhn dn hiu c tc hi ca cc bnh v rng ming, c thc t gi gn

92

hoc cng tc vi cn b y t c chm sc tt rng ming. Mun t mc ch y th trc tin cn phi lm cng tc gio dc sc khe rng ming. 2.1. Gio dc sc khe rng ming 2.1.1. nh ngha Gio dc sc khe rng ming l mt ngh thut truyn b cc kin thc tng qut v nguyn nhn, triu chng, bin chng, cch iu tr, d phng cc bnh rng ming n qun chng, thay i t tng v tp qun c nhm ci thin tt sc khe rng ming cho cng ng. Gio dc sc khe rng ming l mt bin php m mi ngi c hng ng u qua bo ch, truyn thanh, truyn hnh, khng phn bit tng lp x hi, kinh t, vn ha y l mt bin php d phng ch ng (nhn dn ch ng tham gia) nn cn c thi gian ngi dn c th thay i tp qun c, ng thi trc khi gio dc cn phi ch n tp qun, phong tc, tn ngng c th lm cn tr vic t b thi quen c hoc chp nhn mt thi quen mi, kh nng kinh t, kh nng nhn thc, kh nng p ng y t i vi cng ng. 2.1.2 Mc tiu Mc tiu chnh ca gio dc sc khe rng ming l cung cp thng tin v kin thc mi v sc kho rng ming nhn dn quan tm v tham gia cng tc phng bnh rng ming, bin hnh ng chm sc thnh hnh ng t chm sc. 2.1.3. Ni dung 2.1.3.1 Ph bin nhng kin thc c bn v rng ming - Chc nng ca rng (nhai, pht m, thm m). - Thi gian mc rng v thay rng cng nhng bin chng khi mc rng. Hm rng sa ca tr cn thit cho n nhai, pht trin c th, khun mt, gi cho rng vnh vin mc khi lch lc..., v th khng nn xem thng vic sn sc rng sa. - Nguyn nhn, triu chng, bin chng, ca bnh su rng v nha chu. - Vai tr ca mng bm rng trong bnh su rng v nha chu. - Nguyn nhn, triu chng ca ung th vng ming. - Tc hi ca thuc l, tru cau, ru i vi ung th vng ming. - Cch pht hin sm cc bnh rng ming (chm en trn rng, au khi n ung nng lnh, chy mu nu, vt lot khng lnh sau 10 ngy iu tr khng sinh, vt trng, hng, nu nim mc ming, vt si chy mu khng au...). 2.1.3.2. Ph bin cch gi gn v sinh rng ming ng phng php V sinh rng ming l tng hp nhng bin php hng ti vic lm sch xoang ming c bit l rng, nu (li), bao gm chi rng v sc ming k sau khi n, dng tm xa rng, ch nha khoa. - Chi rng v sc ming sau khi n L mt cng vic ht sc nh nhng m hu ch, nhng vn cn nhiu ngi cha quan tm cho l cng vic tm thng khng quan trng. Tht ra, y l mt bin php hu hiu nht, d lm nht, r tin nht gi gn v sinh rng ming phng bnh su rng v nha chu. Chi rng l ly i nhng mnh vn thc n, mng bm lm gim mc thp nht s hin din ca vi khun, ng thi cn xoa nn li nh nhng v lm sch vng khe li . Nu chi rng tr thnh mt thi quen hng ngy th chi rng l mt cng vic khng kh v khng mt thi gian, chi rng tht k sau khi n v trc khi ng tt hn chi nhiu ln m cu th. Mun chi rng c kt qu (sch s) cn phi chn bn chi v chi rng ng phng php.

93

+ Chn v gi gn bn chi: Bn chi sau khi dng ry kh v ni thong, khi lng bn chi b ta th phi thay bn chi khc + Phng php chi: c nhiu phng php nhng phng php Bass d thc hin v lm sch c mng bm c rng, rnh nu v k rng, ng thi kch thch nu. Mt ngoi: t lng bn chi ti c rng, nghing mt gc 45, hng v pha nu (so vi trc rng). C ng ti lui nh ti ch, va p va cho lng bn chi i vo rnh n v k rng, sau ht xung v pha mt nhai. Mi vng lm 5-6 ln ri chuyn sang vng khc. Mt trong cng nh trn Mt nhai chi ti lui hay xoay trn + Thi gian chi: tt nht chi sau khi n, hoc mt ln (ti) hoc 2 ln (sng, ti) - Tm xa rng: ch dng khu thc n git k rng, khng dng xa ti lui cc k rng v s rng k v mn men rng. - Ch nha khoa dng ly thc n nhng k st 2.1.3.3. Ph bin v vn dinh dng trong bnh rng ming Dinh dng (cht lng, s lng, s ln n) nh hng trc tip trn rng v vi khun, lm gia tng hoc lm chm cc bnh rng ming. Dinh dng nh hng trc lc mc rng (c cu, thnh phn ha hc ca rng), giai on mc rng v sau mc rng (to mi trng nui dng, hot ng ca vi khun trn rng, gia tng mng bm). V vy, chng ta cn hng dn dinh dng cho cng ng d phng v kim sot bnh rng ming ca bn thn v gia nh. Hng dn cch n, cht dinh dng v dng thc phm. - Cht dinh dng Cc thc phm tt cho sc khe ton thn cng nh cho rng gm : + Calci: c trong sa, phma, u nnh, thn, cc loi u, rau ci, bng ci xanh, tm cua ... + Vitamin C: c trong cam, chanh, c chua, cc loi rau ci xanh. + Vitamin D: c trong c bin + Carbohydrat: c trong go, bnh m, ng + Protide: c trong cc loi tht, c, trng, u kh Tuy cc cht dinh dng u cn thit cho sc khe ton thn, nhng chng ta nn tng cng n nhng cht dinh dng c cha nhiu calci, vitamin C, vitamin D, protide, cn gim n cc loi carbohydrat. - Cch n Nn n ng ba, ng lc, cc loi dinh dng, trnh n vt nhiu ln trong ngy. - Dng thc phm Nn n loi thc phm t nhin, khng nn n cc loi c ch bin, thc phm ti c nhiu cht x lm sch rng, cn thc phm bm dnh d gy su rng, vim nu. 2.1.3.4. Ph bin cc thi quen, tp qun c hi cho rng ming Mt s thi quen xu c th gy nh hng n rng nh cn nt chai, cn ch, xa rng, b m... hoc nh hng n s pht trin xng hm, khp cn nh mt tay, th ming... n tru, ht thuc l vn c th gy ung th. V vy, chng ta cn phi gio dc cho cng ng hu lm thay i cc thi quen c hi cho rng ming.

94

2.2. Tng sc khng ca rng tng cng sc khng ca rng i vi cc tc nhn gy su rng, chng ta c th s dng rng ri Fluor v cc cht trm bt h rnh. 2.2.1. S dng Fluor Hin nay Fluor c dng rng ri trn th gii phng nga bnh su rng. Fluor l mt cht dinh dng gip cho s tng trng, Fluor bin hydroxyapatit ca men rng thnh fluoroapatit gip rng kh ha tan trong acit, tng ti khong ha, ngn cn s bm dnh ca vi khun... Fluor dit vi khun su rng c bit pH thp (pH < 5,5) Fluor c trong thc phm nh c, tr, bia... Fluor tc dng tt trn b mt lng ca men rng. Fluor c th s dng di nhiu hnh thc: - Ton thn (n ung) Fluor dng ton thn c li cho rng ang hnh thnh v rng mc, Fluor ngm vo men rng ng thi vo mu v tit qua cc tuyn nc bt, dch nu tm cc mt rng. cung cp fluor ton thn ta c th chn 1 trong 4 cch sau: + Fluor ha nc my (0,7 - 1 ppm) chi ph thp, hiu qu cao, an ton, l mt bin php sc khe cng ng cng bng nht, khng i hi s hp tc c thc ca ngi c hng. + Fluor ha nc ung ti cc trng hc gp 4 ln Fluor nc my, s dng cc trng ngoi ni khng c nc my. + Mui Fluoride: 250mg/1kg mui + Vin Fluor (Sodium Fluoride: NaF hoc Acide lated, Phosphate, Fluor: APF) c dng nhng vng c nng fluor trong nc thp hn 0,3 ppm v ung t lc mi sinh n 6 tui vi liu lng 0,05mg/kg/ngy hoc: 0 - 2 Tui : 0,25 mg/ngy 3 Tui : 0,5 mg/ngy 4 Tui : 0,75 mg/ngy 5 - 6 Tui : 1 mg/ngy Vin fluor c nhai trong vng 30 giy cho tip xc vi mt rng ri nut hoc ngm cho tan dn trong ming. - Ti ch Fluor dng ti ch c tc dng hu hiu cho ngi ln v tr em trn rng mc v c nhiu dng s dng: + Sc ming vi nc NaF 0,2 % 1 tun 1 ln + Thoa hoc eo mng c Gel Fluoride + Kem nh rng c Fluor 2.2.2. Trm bt h rnh y l mt phng php d phng su rng h rnh, v Fluor ch c tc dng nga su rng mt lng ca rng, do lm gim su rng h rnh, ngi ta ph mt loi vt liu c tnh cht bm dnh tt ln cc trng v rnh ca rng lm mt i yu t lu gi thc n. Tt nht l cho tt c tr em, nhng do gi thnh cao nn chng ta ch chn nhng em c nguy c su rng v nhng rng c trng, rnh su, ch yu cho cc rng ci sa tr 3 - 4 tui v rng ci ln (hm) th 1 tr 6 - 7 tui, rng ci nh th 1, 2 v rng ci ln th 2 tr 11 13 tui. 2.3. Kim sot mng bm D phng v kim sot bnh nha chu ch yu da vo vic lm sch mng bm. Khi kim sot mng bm nh k, bc s c th ch cho bnh nhn cc vng chi cha sch v hng dn

95

cc bin php lm sch hu hiu hn, ng thi loi tr cao rng iu tr vim nu ngay t giai on u. 2.4. Khm rng nh k Hng nm t chc khm rng ri cho cng ng, hoc khuyn khch nhn dn nn i kim tra rng ming nh k, c bit l tr em, nhm pht hin sm tn thng, nh gi tnh hnh bnh tt, v iu tr sm hn ch gy bin chng.

CU HI T LNG GI
Cu 1. Gio dc sc khe rng ming l mt bin php d phng: A. Kh thc hin B. Th ng C. Ch ng D. Khng cng bng E. Phn bit tng lp x hi vn ha Cu 2: pht hin sm ung th nim mc ming, cn hng dn cho cng ng bit phi i khm ngay khi c vt lot nim mc ming: A. au d di B. Chy mu C. Khng lnh sau 10 ngy iu tr khng sinh D. C b si E. Khng lnh sau 15 ngy iu tr khng sinh Cu 3. Trc khi mc rng, dinh dng nh hng n: A. Thi gian mc rng B. Thnh phn ha hc ca rng C. Thi gian hnh thnh mm rng D. Hnh thi hc ca rng E. Cu to ty rng Cu 4. Calci c nhiu trong: A. Tht B. Trng C. Sa D. u khun E. C bin Cu 5. Chi rng cn: A.Chi nhiu ln trong ngy B. Chi mnh . C. Chi mt ln vo bui sng tht k D. Chi sau khi n E. Chi sau khi ng dy Cu 6. Chi rng l mt bin php gi gn v sinh rng ming: A. Nh nhng v hu hiu B. R tin nhng t hiu qu C. Kh thc hin v t tc dng D. Phc tp nhng hiu qu E. D lm nhng mt thi gian Cu 7. Fluor c s dng di dng ti ch l: A. Sc ming vi NaF D. Mui n c Fluor B. Vin Fluor E. Fluor ha nc trng hc C. Fluor ha nc my

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Cu 8. Trm bt h rnh l mt bin php d phng su rng u tin cho rng ci ln vnh vin th nht tui: A. 2 - 3 tui D. 8 - 9 tui B. 5- 6 tui E. 10 - 11 tui C. 6 - 7 tui Cu 9. d phng bnh nha chu cn i khm ngay khi thy triu chng: A. Tt nu D. p xe nu B. Chy mu nu E. Ming hi C. Rng lung lay Cu 10. S dng vin fluor khi ngun nc c nng fluor: A. < 0,7ppm D. 0,3ppm B. 0,7ppm E. 0,1ppm C. < 0,3 ppm

TI LIU C THM
1. Nguyn Toi, Nguyn Thc Qunh Hoa, L Qu Tho (2003), Gio Trnh Nha Cng ng, B mn RHM Trng H Y Hu 2. B Mn Nha Cng ng Khoa Rng Hm Mt i Hc Y Dc TP HCM (1995), Bi Ging Nha Cng ng

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Chng 13

LIN QUAN GIA SC KHO RNG MING VI SC KHO TON THN

Mc tiu
1 Pht hin c cc du hiu ban u ming khi mc cc bnh nhim trng, nhim c, thiu vitamin, bnh ni tit, bnh mu. 2. Chn on c vim xoang do rng v gi au rng do vim xoang. 3. Chn on c nhim trng mt do rng v au rng do mt s bnh mt.

1. M U
C th l mt khi thng nht, gia cc c quan trong c th khi hot ng u c s phi hp qua li ln nhau. Mt khi xut hin bnh l c quan ny th c th t nhiu nh hng n mt hay nhi u c quan khc. Bnh l rng hm mt cng nh bnh l c quan khc cng khng tch ri quy lut trn. 2. S LIN QUAN GIA RNG MING V BNH TON THN 2.1. Rng ming v cc bnh nhim trng 2.1.1. Bnh si L bnh ly c tnh cht ton thn. Ti ch, vi rt si gy vim ming. Mt trong nhng du hiu xut hin trc khi pht ban ton thn l nhng nt Koplich mu trng xanh nm xung quanh l tit ca tuyn mang tai (ng Stenon tng ng vi vng rng 6 v 7 hm trn). 2.1.2. Bnh thy u C nhng mn sau v ra li nhng vt lot, thng bnh do vi rt. 2.1.3. Mt s bnh khc St pht ban, st xut huyt, cm lm cho nim mc mi kh, li nt n, i khi st cao lm tn thng thnh mch gy chy mu nu. 2.1.4. Vim quanh chp rng mn tnh L nhng nhim trng c nh hng n vim mng ngoi tim, vim khp tay chn. 2.1.5. Vim tu rng cp tnh Cng nh nhim trng rng ming cn c th a n nhim trng huyt v vim nghn tnh mch s mt, nhng bnh ng tiu ho (hi chng suy gim hp thu). 2.1.6. Bnh vim nha chu Lm tng nguy c mc bnh ton thn nh bnh x va ng mch, tiu ng, sinh non v nhng xo trn khc. 2.2. Rng ming vi nhng trng hp b nhim c Khi ti p xc lu v i ho ch t, kim lo i n ng..., con ng i c th b nhi m c; ch ng h n, ng i li xe c th b nhi m c ch, nh ng ng i th m thi c c th b

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nhi m c thu ngn v.v... Ng i ta th y r ng, nh ng ng i b nhi m c ny u xut hi n cc tri u ch ng n u (l i) v r ng, nh n u khng cn h ng nh t v s n ch c n a m c mu en, r ng ng mu... 2.3. Rng ming v vitamin 2.3.1. Thiu vitamin C Vitamin C l mt yu t gip tng sc khng ca c th, chng s nhim trng, nhim c. Thiu vitamin C nh hng n ng rng v m nha chu, c th lm nu rng d chy mu. - Nu vim khng r rng trong thi k rng cha mc, cn khi rng mc m thiu vitamin C nu sng ty ta d lot v chy mu nht l vng rng ca trn. - Rng lung lay do tiu xng , tiu x mng. - Xng hm mc (tiu xng hm). - Nim mc m, vm ming kh - Li trn lng thm kh v au nhc. - Mi kh v nt kho ming. 2.3.2. Thiu vitamin A - Nim mc ming d b hoi t. - Bong cc lp nim mc. - Ming kh. - Chai nu. - Su rng. - Thiu sn men. - Gim st sc khng i vi cc bnh nhim khun. 2.3.3. Tha vitamin A S c cc triu chng chn n, bun nn, chy mu, thiu mu. 2.3.4. Thiu vitamin D nh hng n s bin dng can xi v cu to cc m cng. - Thiu vitamin D xng hm b bin dng (hm h hoc mm). - Rng mc chm, rng chm, rng b x lch v xng hm khng cng chu ng sc p ca lc nhai. - Ri lon th t mc rng. - T chc cng ca rng thiu vng chc. - Rng ngn v nh hn bnh thng. - D thng v hnh dng, v tr, kch thc. 2.3.5. Tha vitamin D - au nhc rng. - Rng mc sm.
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- au nhc xng hm hoc xng sn. 2.3.6. Thiu vitamin B Thiu vitamin B gy nh hng n nu, li, nim mc. - Thiu vitamin B1 (Thiamin clohydrat) gy ri lon chuyn ho albumin. T lm mc vng chc ca rng km i. Gy hin tng t b. - Thiu vitamin B2 (Riboflavin) gy vim mi lot nim mc li v nim mc ming. - Thiu vitamin B5 (axit pantothenic) lm gim s chng ca nim mc khi nhim khun v s bo v i vi t bo biu b. Khi thiu d gy vim mi, vim li v herpes ming. - Thiu vitamin B12 gy thiu mu, au dy thn kinh. Vitamin B12 cn cn thit trong thi k dng bnh cc bnh nhim khun. 2.3.7. Thiu vitamin K Gy chy mu ko di, chy mu t nhin. 2.4. Thiu can xi, fluor Cng lm nh hng n cht lng ca men, ng rng. Ngi thiu nhng cht ny d b mc bnh su rng. Ngc li nng fluor cao trong nc ung li gy nn tnh trng thiu sn men. 2.5. Rng ming v cc bnh ni tit 2.5.1. Ri lon tuyn gip - Thiu nng tuyn gip + Xng s ln v mt tr con v ng ngn. + Xng hm nh, xng hm trn thng b nh ra pha trc. + Rng mc chm v chen chc, + Rng sa rng chm nn thng xy ra hin tng c hai h rng sa v rng vnh vin cng hin din trn cung hm. + T chc cng ca rng yu, chp chn rng m rng v b tiu nhiu. + Xng d b gy . - Cng nng tuyn gip + Rng d b su v s tin trin su rng rt nhanh. + Rng mc sm v rng sa rng sm. 2.5.2. Ri lon tuyn cn gip Dn n ri lon chuyn ho canxi, t nh hng n cht lng ca thn rng. - Thiu nng tuyn cn gip + Ton b xng v rng pht trin chm. + Rng b thiu sn men. - Cng tuyn cn gip + Xng hm b phng ph i v mt cht vi dn n xp. + Rng b gy t nhin. X quang cho thy hnh nh nh knh v.
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+ Rng thng b tu rng. 2.5.3. Ri lon tuyn yn - Thiu nng tuyn yn + Xng hm di nh hp dn n cm ht, xng hm trn t nh hng hn. Ngi bnh c mt chot cm nh nh ming chut. + Rng mc chm v nh hm ch nh. - Cng tuyn yn + Ngi bnh to u ngn bm sinh + Xng hm di pht trin qu mc do mng xng quanh hm pht trin v s tng trng lin tc u chu dn n hm di di hn hm trn. Khp cn cho (cung rng trn nm trong cung rng di). + Rng to v tha. + Mi to v dy. + Mi to. + Li g ph i, tr trc amian v hm ch to hn bnh thng. + Li to v dy gy ni nut kh. 2.5.4. Tuyn sinh dc ( n) - Th i k c kinh nguyt: t ng ti t n c b t d b vim tuyn n c b t. C th b ch c mp, vim nim m c ming. C m n herpes mp, vim n u... - Thi k thai nghn: rng d b v do thiu canxi. Mi tn thng nim mc ming v nu c biu hin cao hn thi k kinh nguyt. - Thi k tt kinh: d b kh ming, vim nu, vim quanh rng, vi ho ng tu... 2.5.5. Tuyn ty Xo trn bin dng trong s cu to cht Insulin gy ra bnh tiu ng. - Nu vim, d chy mu. - M nha chu b suy thoi rng lung lay v tri ln. - Ming kh v hi th hi. 2.5.6. Tuyn thng thn - Thiu nng tuyn thng thn lm chm mc rng. - Cng nng tuyn thng thn lm rng to trong bnh Adison, mt trong ca m v mp mi c vt xm. 2.6. Rng ming v cc bnh v mu (nh hmophilie, hmognie, leucose...) Cng u c triu chng ban u xut hin nu, nh nu vin v gai nu sng phng, chy mu t pht, rng lung lay, ming hi, mi kh, li nt n... 2.7. Rng ming v cc bnh v tim Nhiu cng trnh nghin cu chng minh rng bnh vim mng ngoi tim (Osler) l do cu trng Streptococcus viridans, c rt nhiu cc nhim trng rng ming. Phi nh hoc iu tr tu, cc rng c bin chng tu, vim tu hoc l su st tu.
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2.8. Mi quan h vi bnh tai mi hng - T vim xoang, vim amygdal c th gy ra bnh l rng v nhng m xung quanh. - Ngc li do quan h cht ch v gii phu nn mt khi xut hin bnh l rng, xng hm c th gy ra bnh vim xoang hm hay vim a xoang: + Vim quanh chp, vim nha chu rng ci nh, rng ci ln hm trn. + Tu hoi t ca rng ci nh, rng ci ln hm trn khng c iu tr ng, y cc cht nhim khun qua chp rng vo xoang + Trong khi nh y chn rng vo trong xoang, hoc lm thng xoang. + Vim xng hm trn. + Gy xng hm trn, xng g m gy t mu trong xoang... - Vim ming, vim hng c th lan ra sau gy ra vim hng. - Bin chng mc rng khn hm di lm vim thnh trc hng, vim mt trong cnh cao, lan n vng hnh nhn (amygdale) gy p xe. 2.9. Mi quan h vi bnh ng tiu ho - Ri lon tiu ho: c th biu hin li, nh li c mng trng xm (li bn). - Vim d dy: li c mng vng nht, ming kh. - Vim rut: c nhng t vim nu, vim nim mc ming, i khi c nhng t p t. - Ngc li c bnh l rng v vng quanh rng th gy ra: tiu ho km, hp th gim, vim ng tiu ho. 2.10. Mi quan h vi bnh mt - Nhim khun rng - ming: c th gy ra nhim trng mt. - Chn thng xng hm trn gy Lefort III gy biu hin ri lon th gic, lit mt, lon th, song th, chy nc mt... - Cc u ht chp rng, nht l rng nanh l nhng nhim trng d gy nhim trng xa mt (vim mng b o, nhn cu, p xe mi mt di...) - Bnh glcm cp c biu hin au nhc rng. Trn y l mt s bnh c lin quan n bnh rng hm mt. Khng th ni l y v r rng, nhng mt phn no khng nh rng: khi thm khm bnh l rng hm mt cn phi quan tm n bnh l cc c quan khc trong c th v ngc li. C nh vy, vic d phng v iu tr mi mang li hiu qu cao.

CU HI T LNG GI
Cu 1. Trong bnh si vi rt gy ra: A. Nhng vng lot hoi t ming. B. Hin tng nu mt gai. C. Li nt n. D. Vim ming. E. Vt lot nu c nhiu gi mc. Cu 2. Vim mng ngoi tim c th do nh hng ca bnh: A. Vim ty rng cp tnh. D. Nhim c ch. B. Vim nha chu. E. Vim quanh chp rng C. Nhim c thy ngn. mn tnh
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. Cu 3. Thiu vitamin C c th dn n: A. Thiu sn men. D. Nu chai bng. B. Rng d dng. E. Rng mc chm. C. Nim mc m, vm ming kh . Cu 4. Tnh trng tha vitamin D s gy ra: A. au nhc xng hm hoc xng sn. B. Rng d dng v hnh dng. C. Rng rng chm. D. Rng b thiu sn men. E. Xng hm b bin dng. Cu 5. Thiu nng tuyn gip nh hng n xng hm v rng: A. Xng hm di nh, xng hm trn to. B. Xng hm di nh, xng hm bnh thng. C. Rng nh v tha. D. Rng to v chen chc. E. Rng mc chm v chen chc. Cu 6. Rng mc chm thng thy trong bnh. A. Thiu nng tuyn gip, tuyn cn gip v tuyn yn. B. Thiu nng tuyn yn, tuyn cn gip v thng thn. C. Ri lon tuyn thng thn, tuyn ty v tuyn yn. D. Ri lon tuyn ty, tuyn yn v tuyn thng thn. E. Thiu nng tuyn yn, tuyn gip v tuyn thng thn. Cu 7. Cng tuyn yn s dn n tnh trng: A. Rng to v chen chc. B. Tn ti c hai h rng sa v vnh vin trn cung hm. C. Rng d gy, c hnh nh nh knh v. D. Rng to v tha. E. Rng mc sm. Cu 8. Xng hm di nh, xng hm trn t nh hng (chng cm ht) thng thy trong: A. Thiu nng tuyn yn. B. Thiu nng tuyn gip. C. Thiu nng tuyn cn gip. D. Cng tuyn yn. E. Cng tuyn cn gip. Cu 9. Vt lot do aphte c th kt hp vi mt s bnh l ton thn: A. Vim rut B. Vim d dy C. Thiu vitamin D D. Do nhim c kim loi E. Thiu vitamin A Cu 10. Vim nu c th do: A. Ri lon tiu ho D. Vim a xoang B. Vim d dy E. Vim hng C. Vim rut

TI LIU C THM
Khoa RHM i Hc Y Khoa Hu (2004), Gio trnh KAS

103

104

P N CU HI T LNG GI
CHNG 1 Chng 1 Chng 2 Chng 3 Chng 4 Chng 5 Chng 6 Chng 7 Chng 8 Chng 9 Chng 10 Chng 11 Chng 12 Chng 13
D D B C D D C B D A A C D

2
C B B E D D A C D C D C E

CU HI T LNG GI 3 4 5 6 7 8
A C B E A B A A A C A B C C C B B C D B C C B D C A C C C C D B A B A C E D E C E D A D E C D B E A A E B E B C E D B D B D B A D C C A B D B A B D D A C A

9
D B D C C B A A E D B B A

10
A C C C A D C B B B A C C

MC LC
Li ni u M c l c Chng 1. Rng v b rng Chng 2. S mc rng v d phng lch lc rng Chng 3. Bnh su rng Chng 4. Bnh l ty rng v vng quanh chp Chng 5. Bnh nha chu Chng 6. Vim nhim ming - hm mt Chng 7. Chn thng hm mt Chng 8. D tt bm sinh hm mt Chng 9. Cc khi u lnh tnh hay gp vng ming - hm mt Chng 10. Ung th nim mc ming Chng 11. Chm sc rng ming ban u Chng 12. D phng bnh rng ming Chng 13. Lin quan gia sc khe rng ming v sc khe ton thn p n cu hi t lng gi Ti liu tham kho Trang 1 7 14 24 31 42 54 67 75 80 86 92 98

TI LIU THAM KHO

I. TI LIU TING VIT
1. B Y T (2006), Kin Thc - Thi - K Nng Cn t Khi Tt Nghip Bc S a Khoa. NXB Y Hc H Ni. 2. Nguyn Cn (1998), Bi Ging Nha Chu Hc Tp 1, 2, 3. B Mn Nha Chu Khoa RHM TP.HCM 3. V Th Bc Hi (2003), Gio Trnh Nha Chu, B mn RHM Trng H Y Hu 4. Nguyn Thc Qunh Hoa (2005), Gio Trnh Cha Rng Ni Nha, Khoa RHM H Y Hu 5. Hong T Hng (2001), M Phi Rng Ming, NXB Y Hc TP.HCM. 6. Hong T Hng (2002), Gii Phu Rng, NXB Y Hc TP.HCM. 7. L Hng Lin (2003), Gio Trnh Nh Rng Tiu Phu, B mn RHM Trng H Y Hu 8. Trn Thu Nga (2001), Nha Khoa Tr Em, NXB Y Hc TP.HCM. 9. Trn Thanh Phc (2003), Gio Trnh Chnh Hnh Rng Ming, B mn RHM H Y Hu 10. Trn Vn Qu (2005), Gio Trnh Phu Thut Hm Mt, Khoa RHM Trng H Y Hu 11. V Th Quang (1973), Phu Thut Ming - Hm Mt, NXB Y Hc. 12. Nguyn Toi, Nguyn Thc Qunh Hoa, L Qu Tho (2003), Gio Trnh Nha Cng ng, B mn RHM Trng H Y Hu 13. Nguyn Toi (2003), Gio Trnh Nha Khoa Hnh Thi, B mn RHM Trng H Y Hu 14. Trn Vn Trng (2001), U Lnh Tnh Vng Mt, NXB Y Hc. 15. Trn Vn Trng (2002), U c Tnh Vng Ming-Hm Mt, NXB Y Hc. 16. B Mn RHM H Y H Ni (2001), Bi Ging Rng Hm Mt, NXB Y Hc 17. B Mn Cha Rng Khoa RHM H Y Dc TP HCM. (1998), Bi Ging Bnh L Rng. 18. B Mn Nha Cng ng Khoa RHM H Y Dc TPHCM (1995), Bi Ging Nha Cng ng. 19. B Mn RHM i Hc Y H Ni (1979), Rng Hm Mt Tp 1, 2, 3, NXB Y Hc 20. Khoa RHM i Hc Y Khoa Hu (2004), Gio trnh KAS TING NC NGOI 21. Alsheneifi T., Hughes C.V. (2001), Reason For Dental Extraction In Children, Pediatr-Dent, 23(2), P. 109-112. 22. Archer W. H. (2004), Oral Surgery, W.B. Saunders Company. 23. Grant D.A, Stern I.B, Everett F.G. (2001), Orbans Periodontics, Mosby Company. 24. Gutmann (2002), Problem Solving In Endodontics, Martin Dunitz 25. Jong (2002), Community Dental Health, Mosby Company. 26. Langman J. (1984), Embryologie Mdical, Traduit De L' Anglais Par Pages R. 4me. Ed. Masson. 27. Low W., Schwartz S. (2000), The Effect Of Severe Caries On The Quality Of Life In Young Children, Oral Health. 28. Sapp (2001), Contemporary Oral And Maxillofacial Pathology, Mosby Company.

HON THIN GIO TRNH

THNG TIN V TC GI CA GIO TRNH H v tn: Nguyn Toi Sinh nm: 1952 C quan cng tc: Khoa Rng Hm Mt H Y Dc Hu. e-mail: nguyentoai04@yahoo.com PHM VI V I TNG S DNG GIO TRNH - Ngnh c th tham kho: BS a khoa, Bs gia nh, BS Y hc d phng, CN iu dng - Cc trng: i hc, cao ng, trung cp Y - Cc t kha tra cu: + rng hm mt + su rng + nha chu + ty rng + Vim nhim ming - hm mt + Chn thng hm mt + D tt bm sinh hm mt + Ung th nim mc ming + Chm sc rng ming ban u + D phng bnh rng ming - Kin thc trc khi hc mn ny: y c s v bnh l. - Xut bn: 2008-NXB Y hc NH CH BIN