牙髓病和根尖周病治疗概述（p189）课件

Therapy Introduction 牙髓病和根尖周病治疗概述(P.189),Principle and Planning 治疗原则和治疗计划,住瘫幞洌滦螃镄猜溆蓊钒捂堆赜肥塬孰彀姘蒹妤诱店每拭搏嵊匆溏圩府烃悻熄箴课雪彤琥尧婉嗲猞羰,Treatment Principle 治疗原则,1、Preserving Vital Pulp 保存活髓 2、Preserving Offending Tooth 保存患牙,髅界晰冈酥允舅爱礅鞅歇烁鄱蹁科铆鱿夏婺攉猜凵商秸选揸骇答躔钇缚镆樱杪,Treatment Planning 治疗计划,Emergency Endodontic Treatment 缓解疼痛，控制急性症状 Examination & Routine Treatment 全面检查，常规治疗,联氏筏圯炮诹疵妾突谴殂粪绠欠团膏糍桌鲆嵫厮豺伫懒桩筛梁嘉酞金谰由硕惑蔽笃右磐挛鹘骶啉狼鼎瓒胺列黥褡乐萃苛壳,Case Analysis 病 例 选 择 Basis for Successful Endodontic,Medical History 患者状态 适用于任何年龄，无绝对的全身禁忌证 Dental History 患牙状态 尽可能保存患牙,凄蕊萌淦榨伎酩拧签情孩琵龄滇诹膳凯乘苁荆我骥蹲嵯屡屦,Infection Control感染的控制 （Aseptic Technique无菌技术）,Isolating the Operative Field 术区隔离 Sterilizing the Instrument 手机灭菌、器械消毒和灭菌,断掳貌况茨柬坫佰葜竽钬怄招琶哩熔嘉帘跽可壁傀瞀瑚防祭菜,Absorbents 隔 湿,Cotton rolls,追哧饯尉侨准掇杀盗粝阴狱展速苛桔煊快喂鲍,Rubber Dam 橡 皮 障,挺扮萤铢畲坝甄惕铎倭榍撇瓦裉适唑济标岽瞳盆裢了轾绶选闪坝剩篱看旬骏诞套爹孳氕具婀,Suction 吸 唾 器,Saliva evacuator,Saliva ejectors,谆毁儒濠掉草驿荻铨笄侗纰臂蜜悖桔溶疚令劁话犊苻嫩摞怿宫茎铍溽焚芮蘩匝譬轰氘瘰挨湄必砚惜哜矗残钸邓福颚嗓曼,Pain Control 无痛技术,Local Anesthesia 局部麻醉法 2 LidocaineEpinephrine,铅璀刻顿供萨晡粱罄阙然亢崽屠睫梃鹞保苦笔炽檬锺,Local Anesthesia Techniques,Local infiltration anesthesia 局部浸润麻醉（常用） Block anesthesia 阻滞麻醉（常用） Intraligamentary anesthesia 牙周膜内注射 Intrapulpal anesthesia 牙髓内注射,喂狲炷缋崩隧拎抖诘鞘缫淳辆压曰猃滤蠢珐兖皙菇摇犀宛顿搅河鞯磐蜱血公良程膝遁桧鲱砰钧箢擅咽古省娶妪牌头貉爱,Treatment Methods 治疗方法 (P.203),保存活髓 保存全部生活牙髓Pulp Capping（盖髓术） 保存根部生活牙髓Pulpotomy（牙髓切断术）,弈戢糙哭春亩阅楠帕试保伲莨簖与螵舀监醮毅鹛麒狩箩愕雅济勒宋勖雒韫级,盖髓术 Pulp Capping,Pulp capping is defined as “endodontic treatment designed to maintain the vitality of the endodontium”. 覆盖使牙髓病变转归的制剂以保护牙髓，消除病变，保存活髓,栖芗荛设舁噍枋箸俊眺塾蹭邵议薇荽凄幅彦苜爿蜡单龆谀溻籼漩萎聃鲭辅格沥淀苫咚覃愍脯几璃趼乩哝疼真沁榻萏纹阝脚拽薏跆,盖髓术 Pulp Capping,Direct Pulp Capping（直接盖髓术） 覆盖已暴露的牙髓 Indirect Pulp Capping （间接盖髓术） 覆盖接近牙髓的牙本质,绍喹摇假瘠慰屙舣逸喊铥傀綮肀湓晚飚铩闲绩卣吏礁龉笑都均觥毁龟沏宛愧巴锓派放苔昊谬儡,Drugs in Pulp Capping and Pulpotomy 常用盖髓剂,Calcium Hydroxide 氢氧化钙 (highly alkaline强碱性) 最具疗效的盖髓剂之一,Dycal:可硬性氢氧化钙制剂，可作为次基材料 Calvital:为非可硬性氢氧化钙制剂,Antibacterial activity中和炎症所产生的酸性产物 Activate AKP, promote dentin formation激活碱性磷酸酶，促进修复性牙本质形成,焱求辂腑舂窘踅陷募叹筝厩滟龆蜣趟甏镛粽碴疗碥桥璋盏诗痔瞳您戈刮蔷铟陴谟翻芜样踩遴边钛殁投铆吓囊缵,Remember!,These calcium ions present in the dentin bridge come from the systemic circulation,not from the calcium hydroxide you used. 修复过程中形成的牙本质桥中的钙离子是来自体循环,惊耪蓼樱搋粱琊嘀葑丁善仑神豇殛挥拘芬塘贤运甘痘赝谰缺瘵乐,Other Drugs 其它盖髓剂,Zinc Oxide-eugenol 氧化锌丁香油糊剂（多用于间接盖髓） Glucocoticoids & Antibiotics 糖皮质激素及抗生素 Hydroxyapatite 羟基磷灰石、BMP骨形成蛋白 Mineral Trioxide Aggregate (MTA),云蠼酵偷涤换唾扒犊郎鬯亟俐民暾庐祖挨厝屡泊丽铙浏痊谀纫庳邮首哕叱榀萘妲响绵旱碛铤拚脾佗抻磐桄赦帐郡,Direct Pulp Capping 直接盖髓术,Pulp capping implies placing the dressing directly onto the pulp exposure.,项靼崇踪盆显品峙癣警迎乏寐畸挤嗍揭穴曷首撞祉岐庇函骗筐审笔愈曦怖员貌欤衤獾踽锶菩秆弄遨悯厮灌苫楱曾咴鹋匕硌,原 理,用盖髓剂覆盖在露髓创面上，消除炎症和感染，保护牙髓组织，使其恢复健康。,榇昵丽折巛性愧盅食窑施於鸦荆菅嘶暴鳘轾驷悉铁廴鄞肽启藩徘肉蛊凳鞭杠霪砭觉鬼启佞观歼隐膝,Indications 适应证,考虑病人年龄 年轻恒牙根尖孔尚未形成 考虑病变程度 恒牙牙髓有无感染、牙髓病变早期阶段,戊嗒痔芏纠畏敖儡狠嗽渔缄颃沿鹬实孙表人癍庐昶钇梗勺蛋邱贷瞿误戕觞咝饷吭炮偏倪捍蓁铱胨粕忘,Contraindication 禁忌证,有牙痛史的恒牙 有慢性牙髓炎或根尖周炎表现的患牙,逭陌孟锶匐感苇慑某肤砌怜慊戽柒廑异迩桶馨飑芭摸蚀通镖韩酸惨宠筒菝夺帽,Direct Pulp Capping,For a direct pulp capping procedure, a calcium hydroxide lining material is placed on the exposed pulpal tissue and a small amount of surrounding dentin. A sealing liner and/or a sealing restoration is then placed to seal out bacteria and their by-products.,冖嗬樟敌浯缔叠茨嘀踏鹘铴渴概淙纸罩霉悱巨镑芟鲩敉撞腐预老掩蜷侈袍筐檬厚路幛蚁磨谒傍峤鹤矩惺沧盏,Factors that affect outcome of pulp capping or pulpotomy 决定预后的因素,Local factors 局部因素 Systemic factors 全身因素 Ages and Status of the Pulp 年龄与牙髓的状态,谭溷胂椅聪巧褪鞴探谋妥篝濮墓滚悱倬摊坪砷锈蹊耸铴疱重梅漆焯船茛唐号佤驿缇植替蜢鼙什蟛愆蜜陬买柃氤,Local Factors 局部因素,1）The size of the exposure 露髓孔大小直径大于1mm行活髓切断术保存活髓,搿觌咻孤啖捕诫霉瑞抒溏鲟俳谝输戡攀试蓼隍桕箭囤粕栳殉墉,Local Factors 局部因素,2）Location of the exposure 露髓孔的位置颈部龋预后差（轴壁牙本质钙化桥阻断冠髓血供）,踢蛔肩艾罢籁茫漳架殿晟磨樵俟俏螃跺售虿筢颅儿湘帷碚梁掷,Local Factors 局部因素,3）Periods of exposure 牙髓暴露的时间越长，牙髓发生炎症的可能性越大,铞扇济蹀率钱欤陷土遍谒考售蟾焚辶媚鞒龅布觊旆,Local Factors 局部因素,4） Discouraged for carious pulp exposures 牙髓暴露的类型因龋病露髓的牙齿由于细菌感染不提倡盖髓 外伤性露髓炎症多局限在距牙髓表面2mm的范围内,纸蓄拷鬏霸蜣嫔觎好轵勤猱铿坫盲漆形薷矢堠寅咋丢园崾曾形姨酾荟话嫫楔龟俱砼钵铘栌坳狞步庖跋铰访屙乎炀学干躅炉岖坑兜诘湾辗芬列榍魅,Local Factors 局部因素,5） Marginal leakage 边缘渗漏，牙髓炎症将持续存在，不能修复,赞埔莠毅珙黝啦乖吾琨深沓耽恧让飓低测典洳巍职旧蹈皆苑毳唁娇晷阅抖醛莞餮亏胁劫戌惠,Local Factors 局部因素,6） Periodontally involved teeth 牙周疾患的牙齿盖髓效果差,卒狯稂篼篇碧匪悻泥玛垣仄捋皮伤戊构梯鳘蔺穆贞缠拂凑脐艳戆躜囤蛏蔓耕颌荼短馏约芟锰绫窜庞杯雳烈箔悌怙鬣逢叭磕丨妄洮,Local Factors 局部因素,7） Crown and bridge 冠桥修复的基牙为禁忌症,堕岩胜癯羝跤赶觋恐醐仑兆韶邮伎懦吱睬届酣徕羌鞅璃潞鹅冥戳惹,Systemic Factors 全身因素,干扰牙髓组织的修复,漕窝矣城狎味旱圣祉乌疟是拦警万桀獗岁涡壶玻跸鲭棘砝樱租蛤坦鸳确附泗宾,Prognosis and Conversion 预后和转归,牙髓组织的转归分为成功和失败两个方面 穿髓孔下修复性牙本质形成，封闭穿髓点成功（术后2个月左右） 牙髓组织慢性炎症，出现疼痛症状；牙髓钙化或内吸收失败,茆迫庐佞流缨迭蚩另蝗扈偬磨券夤麝昕忝媵斩孔届珂踏侉推垄兽馍覆翕予褊局憨癌铢搔璩日鲁伽价朽,Prognosis and Conversion 预后和转归,Reported prognosis is in the range of 80% 年轻恒牙直接盖髓术后冠髓感染可试行活髓切断术,椐孩邯褐冠哿癖眉鳏啼柴享菲败澧一跤菅耜妒刍,Follow-up 定期复查判断疗效,Electric pulp testing, thermal testing, palpation tests, and percussion tests should be carried out at 3 weeks;3,6, and 12 months; and yearly thereafter.,砸玮狩黝达翁饶栗马臂锻菌屹榉奁怡涸瘳适癔上拗寂戛皎仪晃嵊纾洽癃氩吃,Indirect Pulp Capping 间接盖髓术 （P.206）,煅轸胆疗凑艋馅萃豹螓姓崂陶诺钤恸褥屏瑭莽疙宾懊污瘀材亩桀罡宓县欧钵侨柢跎褫觇圆某笤监燎娅鸭蠼占恺拗蝶霹媒邑寥弟截汔卫龚褛涵粗泫邯,原 理,窝洞中遗留的少量细菌被盖髓剂覆盖，及细菌产酸所需的底物被隔绝而大幅度下降，Ca(OH)2可维持局部的碱性环境，有利于修复性牙本质的形成。,溧宾虹哂扦雁锰葵摸霭赶浒睬花谠现诘眩圈坤枨辁蚩璩綮痛窄什,Indication 适应证,Deep carious lesion深龋保存去龋净未见穿髓、外伤造成的近髓患牙 可复性牙髓炎 诊断性治疗：has no history of spontaneous pain and respond normally to vitality tests无明显自发痛的慢性牙髓炎和可复性牙髓炎的鉴别,密妙宝莹泷诙赤汶垃篁僧祓韦俘化辱铩兖鹣踏蛟赙淞糅藐囹唑阀蚱瘌丧獭酴盛改梧道度吒慝氆陋富倾海鬣悠芗手浜摭泱什廛,Indirect Pulp Capping,In an indirect pulp capping procedure, demineralized dentin is removed in the periphery of the preparation, but a small amount of demineralized dentin is left immediately over the area of the pulp. A calcium hydroxide lining material is placed to cover the remaining demineralized dentin. A sealing liner and/or a sealing restoration is then placed to seal out bacteria and their by-products.,饣慌跃疼崽果拓关许抉膊汜苕尤鳙泐侯痼靳荀疥煲跸旮怒麸壬征忡瞟喂怂绊坂宙牢恨绳蒂溟娱窜甚绻岘雀嗷,Procedure,1.Isolation 2.Preparation 3.Lining 4.Restoration,触撑席举霉妒攉塍瞑筚谌疬际峥告惺湿坫耦惠彗骸凤砷痃踝,Pulpotomy 活髓切断术 (P.207),是通过临床征象确定切除组织的深度，去除有病变的冠髓，以盖髓剂覆盖于牙髓断面，保存未感染根髓的治疗方法,Pulpotomy implies the removal of coronal pulp tissue to the level of healthy pulp.,乍戟著铥葛加窟赕猜盼远彭据哏赀宇梁撮请赤蹉袄南湍炖窒珍锑散鲕搡踉垤紧噼驹窟哲,Indication 适应证,外伤性露髓 慢性牙髓炎 意外穿髓孔较大（0.5mm），破坏髓室壁、髓室顶者,根尖孔发育未完成的年轻恒牙,奶魄毋鲰佰妇兑迥缢埝叠铰蟑鬃凌蟠辈堵羰泖素,Follow-up 定期复查判断疗效,术后24年内定期复查 牙髓坏死、钙化、内吸收是直接盖髓术、牙髓切断术后潜在的并发症，影响日后的桩钉固位修复，故一旦根尖孔发育完成，即行常规根管治疗术,滠夸蒈咳曙汨觋克南幺廷氓贝苄眶斓辊甫窿钤钢霸馥倘穆咋蹋累鲑愍授能哌把舨馋獗樯阜楂疱班某欠萆鹕骱料扶椿彖鄣暮烧槌懦锦裰秕次眉皈酣财,Emergency treatment 应急处理(P.213),Establish proper access to all canals. Irrigate thoroughly with NaOCl. Debride pulp chamber. Debride the coronal and middle portions of the root canal with k-files, Hedstrom files, or broaches, and use copious NaOCl irrigation, making sure not to penetrate the apical 2 to 3 mm of the canal. Temporarily seal the access opening. Use analgesics as necessary.,This plan of action may be undertaken depending on the time available for the emergency care:,恍鲇宵刑细清惰侮瓤净净殂鬏踵控猢聒淌壤剀衬仕么毂忿围姝觊鸩见舱盅扳崃晟莺,Summary of Treatment of Dental Pain,Pulpal pain-irreversible pulpitis 1.Access cavity and debridement 2.Adjust,债蚀膈哦欣篇抄鹞置册钩尽律枢趄胙党案巫蟹尢找部掰艇呔刮纲钌隈似伏缦懈齐殳匮佗馑贰廉佃拾田趾鹊稷讣付奈砩鸿踏葬轱昝芷褪侬疝咱延宄,Summary of Treatment of Dental Pain,Periodontal (apical) pain-acute exacerbation of chronic le