病例选择与治疗计划.ppt

TreatmentofPulpalandPeriapicalDiseases,1.CaseSelectionandTreatmentPlanning病例选择与治疗计划,Pathwaysofthepulp,8thedition,ChapterOutline,CommonmedicalfindingsthatmayinfluenceendodonticsDentalevaluationTreatmentplanning,1.1Commonmedicalfindingsthatmayinfluenceendodontics,1.1.1Pregnancy,NotacontradictiontoendodonticsModifiedtreatmentplanDeferelectivedentaltreatmentduringthefirsttrimesterexceptemergencytreatmentProvideroutinedentalcareduringthesecondtrimesterConsultphysicianifnecessary,1.1.2Cardiovasculardisease,MedicallycompromisedpatientsConsultwithphysiciansbeforeinitiationoftreatment,Myocardialinfarction心肌梗死(heartattack)withinpast6monthsIncreasedsusceptibilitytorepeatinfarctionsandothercardiovascularcomplicationsContraindicationtoanyelectivedentalcare,PatientswithahistoryofHeartmurmur心脏杂音Mitralvalveprolapsewithregurgitation二尖瓣回流Rheumaticfever风心病Congenitalheartdefect先心病Artificialheartvalves人工瓣膜Increasedsusceptibilitytoinfective(bacterial)endocarditis细菌性心内膜炎PotentiallyfatalcomplicationProphylacticantibiotictherapy预防性使用抗生素,CoronaryarterybypassgraftAntibioticprophylaxisisnotneededafterthefirstfewmonthsofrecoveryConsultationisadvised,1.1.3Cancer,Patientsundergoingchemotherapyand/orradiationtotheheadandneckImpairedhealingresponsesConsultthepatientsphysicianbeforeinitiationoftreatment,1.1.4AIDS,InfectioncontrolAsymptomaticpatientsareusuallycandidatesforendodontictreatmentMedicalconsultationbeforeendodonticsurgeryforHIV-infectedpatients,1.1.5Diabetes,WellcontrolledpatientsarecandidatesforendodontictreatmentMedicalconsultationforpatientswithseriouscomplicationsorbeforeendodonticsurgeryRenaldiseaseHypertensionCoronaryatheroscleroticdisease冠状动脉粥样硬化,1.1.6Dialysis透析,BleedingtendencyElectiveendodontictreatmentshouldbepostponed,1.1.7Prostheticimplants,HeartvalvesVasculargraftsPacemakers起搏器CerebrospinalfluidshuntsProstheticjoints人工关节AntibioticprophylaxistopreventinfectionatthesiteoftheprosthesisMedicalconsultationhighlyrecommended,1.1.8Behavioralandpsychiatricdisorders,ConsultationbeforeusingSedatives镇静剂Hypnotics催眠药Antihistamines抗组胺药,1.2Dentalevaluation,PeriodontalconsiderationsRestorativeconsiderationsEndodonticconsiderationsSurgicalconsiderations,1.2.1Periodontalconsiderations,PeriodontalprobingMobilityassessmentRadiographicassessmentEndodontictreatmentshouldnotbeplannedforteethwithpoorperiodontalprognosis(e.g.mobilityIII),1.2.2Restorativeconsiderations,RestorativetreatmentplanningbeforestartingendodontictreatmentinanonemergencysituationExtensivelossoftoothstructureSubosseousrootcaries(crownlengtheningmaybeneeded)Poorcrown-rootratioLackofferruleeffectMisalignedtoothConsultationwithaprosthodontist,1.2.3Endodonticconsiderations,AnatomyofrootsandcanalsProceduralerrorsSmallmouthInstrumentsOperatorskillTimeTodeterminethelevelofanticipateddifficultyToidentifycasesthatshouldbereferred,1.2.4Surgicalconsiderations,OfparticularvalueinthediagnosisofnonodontogeniclesionsBiopsypriortodefinitiveendodontictreatment,1.3Treatmentplanning,ScopeofendodonticsVitalpulptherapy活髓保存PulpectomyorRCT牙髓摘除术或根管治疗Endodonticsurgery牙髓外科Retreatment再处理Hemisectionorrootamputation牙半切或截根术Bleaching牙漂白Apexificationorapexogenesis根尖发育成形术或根尖诱导术,Treatmentplanning,Treatmentorextraction?Whatkindoftreatment?EndodonticPeriodontalRestorativeWhowillbetheoperator?Single-visitormulti-visit?CostPrognosis,2.Preparationfortreatment,InfectioncontrolUniversalprecautions(operatorypreparation)InstrumentsterilizationToothisolation患牙隔离PatientpreparationInformedconsent知情同意Paincontrol,2.1InfectionControl,DentalpersonnelareatriskofexposuretoahostofinfectiousorganismsRiskofcross-contaminationinthedentalenvironment,EffectiveinfectioncontrolproceduresReducethenumberofmicro-organismsintheworkingenvironmentProtectpatientsandthedentalteamImprovetheoutcomeofendodontictreatment,Universalprecautions,AmericanDentalAssociation(ADA)recommendationEachpatientisconsideredpotentiallyinfectiousThesamestrictinfectioncontrolpoliciesappliedtoallpatients,Infectioncontrolguidelines,DentalpersonnelvaccinatedagainsthepatitisBThoroughandupdatedpatientmedicalhistoryProperbarriertechniquesfordentalpersonnelMasks,protectiveeyewear,disposablelatexglovesHands,wristsandlowerforearmswashedwithsoapUseofvacuumsuction(high-volumeevacuation)forhigh-speedhandpiece,watersprayorultrasonicsUseofrubberdam,Cross-contaminationrelatedwithhandpiecesSurfacecontamination表面污染Aircontamination空气污染Suctioncontamination回吸污染,RubberDam橡皮障,RoutineplacementoftherubberdamisconsideredthestandardofcareinUSA,Reasonsforuseofrubberdam,ProtectionaspirationorswallowingofinstrumentsorirrigantsSofttissueinjurycausedbyinstrumentsEfficiencyImprovevisibility(dryfieldandreducedmirrorfogging)MinimizepatientconversationMinimizetheneedforfrequentrinsingReducedriskofcross-contaminationLegalconsiderations,Componentsofrubberdamsystem,Rubberdam(sheet)橡皮障Frame橡皮障架Retainers(clamps)橡皮障夹Punch橡皮障打孔器Forceps橡皮障钳,2.2Informedconsent,ContinuousriseindentallitigationForconsenttobeinformedTheprocedureandprognosismustbedescribedAlternativestotherecommendedtreatmentmustbepresentedalongwiththeirrespectiveprognosesForeseeablerisksmustbedescribedPatientsmusthavetheopportunitytohavequestionsanswered,根管治疗知情同意书请阅读以下同意书，若您同意下列内容，请在治疗开始前签字。本人因诊断为_,同意授权_医生进行_的根管治疗（镍钛机动预备/手动预备，热牙胶充填/冷侧压充填）。同时我也同意上述医生在他(她)认为必要(或按治疗计划认为必要)的情况下照X线片，使用药物治疗、麻醉以及相关设备或处理措施。本人已充分理解根管治疗是保留患牙的最佳治疗方法。完善的根管治疗较其它牙髓治疗难度大、费时，需要精良的器械和技术，费用也较高。根管治疗需要去除牙内感染的牙髓组织（含血管、神经），然后用充填材料封闭根管。根管治疗成功率较高。但少数患牙因牙齿本身的情况较复杂，也可能需要再处理、根尖周手术甚至被拔除；在治疗过程中，可能出现器械折断于根管内、根管壁侧穿或髓底穿以及牙体折裂。治疗之后，患牙通常需要以桩核或全冠修复来保护和恢复患牙功能，否则易发生牙体折裂。根管治疗与麻醉的常见并发症包括：疼痛、肿胀、牙关紧闭、感染、出血以及唇、牙龈或舌的麻木，但麻木极少持续。我已了解了根管治疗的情况,就诊医生已向我介绍了根管治疗（镍钛机动预备/手动预备，热牙胶充填/冷侧压充填等）具体步骤及相应特点。我的疑问也已从就诊医生处得到满意的回答。本人同意医生采用_治疗方案，具体治疗费用约_元。患者姓名：_时间：_患者签名（若患者为未成年人则由监护人代签）：_主诊医生签名：_时间：_,2.3Paincontrol,LocalanesthesiaDivitalization失活法,2.3.1Localanesthesia(LA),WhentoanesthetizeLAshouldbegivenateachappointmentThreemisconceptionsNecroticteethmaybeinstrumentedwithoutLA(vitaltissuemayexistsperiapically)Patientssenseaidsthecliniciantodetermineworkinglength根管工作长度LAisunnecessaryduringobturationphase(obturationpressureandextrusionofsealermayproducepain),localanesthetics,Lidocaine利多卡因Articaine阿替卡因,碧兰麻(阿替卡因),Techniques,ConventionaltechniquesSupraperiostealinjection(localinfiltration)RegionalnerveblockSupplementaltechniquesPeriodontalligament(PDL)injectionIntrapulpalinjectionIntraseptalinjectionIntraosseous(IO)injection,MaxillaryposteriorteethPosteriorsuperioralveolar(PSA)blockformolarsBuccalinfiltrationforpremolarsPalatalinfiltrationforrubberdamretainer(optional)MaxillaryanteriorteethLabialinfiltrationPalatalanesthsiaforrubberdamretainer(optional),MandibularteethInferioralveolarnerve(IAN)blockforanteriorandposteriorteethIncisivenerveblockforpremolarsandanteriorteethLabialinfiltrationforanteriorteeth,Periodontalligment(PDL)injection,27-gauge/shortor30-gauge/ultrashortneedlePlacedintotheperiodontalspacebetweentherootandtheinterseptalboneBevelfacingtheroot0.2mLofanestheticslowlydepositedonthedistalofeachrootofthetooth,IndexofsuccessfulPDLinjectionPresenceofresistancetoanestheticdepositionIschemiaofthesofttissueatthesiteofinjectionContraindicationsPresenceofinfectionorinflammationintheareaofneedleinsertion(e.g.acuteapicalabscess),Intrapulpalinjection,27-gauge/shortneedleInsertedintothepulpchamberorcanalResistancemetand0.20.3mLofthesolutionexpressedInlackofasnugfitoftheneedlewarmguttapercha牙胶insertedaroundtheneedleInjectionunderpressureaftercooling,2.3.2失活法Devitalization,用化学药物封于牙髓创面上，引起牙髓血运障碍而使牙髓组织坏死失去活力，以达到无痛操作使牙髓失活的药物称为失活剂,失活法可以有效地达到无痛操作，常规用于干髓治疗。其他去髓治疗在麻醉效果不佳，或对麻醉剂过敏时才采用失活法,常用失活剂,多聚甲醛（三聚甲醛，简称“三甲”）引起牙髓血运障碍而发生坏死毒性弱于亚砷酸较安全作用相对缓慢封药时间：全牙髓14天根髓7-10天,常用失活剂,亚砷酸（As2O3）毒性强：细胞原生质、神经、血管作用迅速：牙髓血运的影响无自限性：化学性根尖周炎严格控制封药时间：24-48小时禁用于根尖孔未形成的患牙,操作步骤,告知患者：选择失活剂、按时复诊暴露牙髓：不强调彻底去腐减压引流、控制出血：酚、肾上腺素棉球放置失活剂：小球钻大小+丁香油棉球ZOE暂封窝洞,失活法增加就诊次数牙体变色适用于后牙失活不全,麻醉法缩短疗程适用于全口牙作用迅速完全,3.VitalPulpTherapy活髓保存治疗,Indirectpulpcapping间接盖髓术Directpulpcapping直接盖髓术Pulpotomy牙髓切断术“Principlesandpracticeofendodontics”2thedition,3.1Indirectpulpcapping,IndicationsdeepcariouslesionsNohistoryofpulpalgiaNosignsofirreversiblepulpitisNopulpexposureafterexcavationofcariousdentine,PulpCappingMaterials,Calciumhydroxide氢氧化钙Themostcommonly-used(direct)pulp-cappingmaterialWater-basedcalciumhydroxideResin-basedCalciumhydroxidee.g.Dycal,Timeline,Zincoxide-eugenolcement(ZnOE)OnlyforindirectpulpcappingBactericidaleffectandhermeticmarginalsealCytotoxicity-useofZnOEasalinerindeepcariouslesionsisstillcontroversial,Procedures,1.Removeallsoftened,mushyorleatherydentine2.EitherZOEorCa(OH)2placedontheremainingdentintokillorsuppressbacteria3.Base4.Temporaryorpermanentrestoration,3.2Directpulpcapping,Indications:Accidentalormechanicalpulpexposure(normalpulp)CavitypreparationPlacementofpinsTraumaMainlyforimmaturepermanentteethwithrecent(24hr)traumaticpulpexposureormechanicalexposureduringcavitypreparation,Shouldmatureteethbepulpcapped?Sizeofexposurelimitedto1mmContraindicatedforcarioustoothwithpulpinvolvement,Enamel-dentinfracturewithpulpalinvolvement,Directpulpcapping,Hemostaticreagents止血剂,Saline盐水Hydrogenperoxide双氧水Dilutedsodiumhypochlorite次氯酸钠Chlorhexidine洗必泰,Pulpcappingmaterials,CalciumhydroxideMineraltrioxideaggregates(MTA)矿化三氧化聚合物,Procedures,Ca(OH)2appliedtotheexposuretostimulatedifferentiationofnewodontoblast-likecellsandformationofsecondarydentinTemporaryrestorationplacedoverCa(OH)2Follow-upPermanentrestorationPulpotomyorendodontictreatmentforsymptomatictooth,3.3pulpotomy,Indication:Immaturepermanentteeth,Procedures,RemovalofallcariousdentinandpulptissuetotheleveloftheradicularpulpVitalpulpstumpcappedwithCa(OH)2TemporaryrestorationFollow-upAsymptomatic:permanentrestorationSymptomatic:endodontictreatment,Potentialproblemswithpulpotomyasapermanenttreatment,ImpossibletodeterminewhetheralldiseasetissuehasbeenremovedTheremainingradicularpulptissuemayundergomineralizationMakingfurtherendodontictreatmentdifficultorimpossibleInternalresorption,Conclusions,Thevitalpulptherapiesarepredictableinteethwithtraumaticormechanicalpulpexposure.Directpulpcappingiscontraindicatedforteethwithcariouspulpexposure.Pulpotomymightbethechoicebutisconsideredunproven.Whenforfinancialorotherreasonsextractionistheonlyalternative,pulpotomycertainlyshouldbeconsideredforthebenefitofthepatient.,4.EmergencyTreatment,PretreatmentemergencyIrreversiblepulpitiswithoutacuteapicalperiodontitisIrreversiblepulpitiswithacuteapicalperiodontitisPulpnecrosiswithacuteapicalperiodontitisPathwaysofthepulp,8theditionPrinciplesandpracticeofendodontics,2thedition,4.1IrreversiblepulpitiswithoutAAP,Principles:CompletepulpremovalTotalcleaningandshaping(C/S)oftherootcanalsystem根管清理和成形Pulpectomyisthebesttoachievepainrelief,PulpectomyCompleteremovalofthevitalpulptissuefollowedbycleaning,shapingandfillingoftherootcanal(s).Indicatedfortoothwithpulpitis,MultirootedteethattheemergencyvisitPulpotomy(removalofthecoronalpulp)orpatialpulpotomy(removalofthepulpfromthewidestcanal)acceptablebutlesspredictableinpainrelief,Procedure,C/SoftherootcanalsystemAdrycottonpelletplacedinthepulpchamberCompletecariesremovalandeffectivetemporarycoronalsealtopreventcontaminationOcclusalreduction咬合调整,4.2IrreversiblepulpitiswithAAP,CombinationofpulpalandperiapicalsymptomsCompletepulpremovalandC/SCa(OH)2medicationincanalstopreventbacterialregrowthEffectivetemporarycoronalsealOcclusalreductionOralanalgesicmedicationwhennecessary,4.3PulpnecrosiswithAAP,WithoutswellingWithlocalizedswellingWithdiffuseswelling,Withoutswelling,ThoroughremovalofnecroticpulpCompleteC/SoftherootcanalIntroducingasmallfile(#10/15)slightlybeyondtheapextoestablishdrainagefromtheperiapicalt