牙髓病和根尖周病诊疗概述

1、牙髓病和根尖周病诊疗概述Principle and Planning 治疗原则和治疗计划Treatment Principle 治疗原则1、Preserving Vital Pulp 保存活髓 2、Preserving Offending Tooth 保存患牙 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Case Analysis 病 例 选 择Basis for Successful EndodonticMedical His

2、tory 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Absorbents 隔 湿Cotton rollsRubber Dam 橡 皮 障Suction 吸 唾 器Saliva evacuatorSaliva ejectorsPain Control 无痛技术Local Anesthesia 局部麻醉法2 L

3、idocaineEpinephrineLocal Anesthesia TechniquesLocal 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 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） 盖髓术 Pulp CappingPulp capping is defined

4、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，保存活髓盖髓术 Pulp CappingDirect 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 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

5、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Other Drugs 其它盖髓剂

6、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)Direct Pulp Capping 直接盖髓术Pulp capping implies placing the dressing directly onto the pulp exposure.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。Indications 适应证考虑病人年龄 年轻恒牙

7、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Direct Pulp CappingFor 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

8、placed to seal out bacteria and their by-products.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 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Local Factors 局部因素2）Location of the exposu

9、re 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）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Local Factors 局部因素6） Periodontally invol

10、ved teeth 牙周疾患的牙齿盖髓效果差Local Factors 局部因素7） Crown and bridge 冠桥修复的基牙为禁忌症Systemic Factors 全身因素干扰牙髓组织的修复 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Foll

11、ow-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.Indirect Pulp Capping 间接盖髓术 （P.206）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。Indication 适应证 Deep cariou

12、s 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Indirect Pulp CappingIn an indirect pulp capping procedure, demineralized dentin is removed in the periphery of the preparation, but a small amount of demineralized

13、 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. Procedure1.Isolation2.Preparation3.Lining4.Restora

14、tionPulpotomy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.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

15、发育完成，即行常规根管治疗术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 t

16、he 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:Summary of Treatment of Dental PainPulpal pain-irreversible pulpitis 1.Access cavity and debridement 2.Adjust

17、Summary of Treatment of Dental PainPeriodontal (apical) pain-acute exacerbation of chronic lesionNo obvious swelling （acute apical periodontitis）1. Debridement2. RCT a.s.a.p.Local swelling （acute apical alveolar abscess）1. Debridement to allow maximum drainage2. Clean canal 3. Incise if fluctuant 4. RCT a.s.a.p.Local swelling and “cellulitis”1. Treatment as above2. Antibiotic therapy3. When drainage from root can