（P43-51）caries manifestation-口腔专业课课件-牙体牙髓病学

ClinicalManifestationandDiagnosisofDentalCaries皮根莉讲师牙体牙髓病学教研室pi779@pathologicalprocessofdentalcariesclassificationofdentalcariesdiagnostictechniquesfordentalcariesclinicalmanifestationofdentalcariescontentsDefinitionofDentalCariesDentalCariesisakindofinfectivediseaseoccurredinthehardtissueofthetooth.DentalCariesisanirreversible,slowlyprogressivedecayofapatites(羟磷灰石)anddecompositionoforganicsubstancewhichleadstoadisintegrationoftoothstructureandcavitation.demineralizationremineralizationCavityformedLesionrecoveredCariesisadiseasewithalternatingphasesofdemineralization(脱矿)andremineralization(再矿化).Cariouscavityiscausedbythedestroyedbalancebetweendemineralizationandremineralization.Demineralization&Remineralizationdemineralization

Becauseoftheactionofacid,themineralsinthetoothisdissolved.Thecalcicandphosphaticionsarereleasedfromthetoothtissue.在酸的作用下，牙齿矿物质发生溶解，钙和磷酸盐等无机离子由牙中脱出称为脱矿。(P46)remineralization

theprocessthatcalciumandphosphatedepositintothenormalorpartiallydemineralizedenamel.再矿化是指使钙、磷和其他矿物质离子沉积于正常或部分脱矿的釉质中或釉质表面的过程。(P47)conceptspathologicalprocessofdentalcaries表层

(surfacezone)病损体部(bodyofthelesion)暗层(darkzone)透明层(translucentzone)EnamelCaries1.Demineralizationoccursunderthesurface----translucentzone脱矿最早表现为表层下出现透明带，临表及X线片不能发现。2.Thedarkzoneisformedbecauseofremineralization.透明带扩大，由于再矿化，中心出现暗带。3.Thedevelopmentofdemineralizedtissuecausestotheformationofthebodyofthelesion.随着脱矿病变的发展，出现病损体部。临床表层为白斑。4.Pigmentationoccurs.

Thelesionisbrown.外源性色素沉着于病损体部，临床表现为棕色褐斑。5.ThelesiongetstoDEJ,andtheundermineddefectisformed.龋损进展到釉牙本质界，侧向扩展，发生潜行性破坏。临床表现为蓝白色。6.Thecariouscavityisformed.牙齿表面破坏，龋洞形成。ClassificationofDentalCariesClassificationstandardsCariesprocessLesionsitesSeverityofthelesionClassification1CariesProcess按发病情况和进展速度分类acutecaries急性龋chroniccaries慢性龋developingrateprimarycaries原发龋secondarycaries继发龋originalsituationThecariesprocessdevelopsrelativelyfast.病变进展较快。Thedecayedtissueislight-colored,soft,andwet.病变组织颜色较浅，质地软而湿润，又称湿性龋。Alittleofreparativedentinisformedbecauseoflesstime.Thepulpislikelytobeaffected.修复性牙本质形成较少，牙髓易受感染。Itoftenoccursinchildrenandteenagers.多见于儿童或青年人。AcuteCariesSpecialtypeofacutecaries猖獗龋(猛性龋,rampantcaries)akindofseveredecayonmultiplesurfacesofmanyteethinashorttime.多数牙在短期内同时患龋。Itmaybearesultofpreviousradiationtotheheadandneck—radiation-inducedcaries.常见于颌面及头颈部接受放疗的患者，又称放射性龋。PatientswithSjögren'ssyndromePersonswithsystematicdisorders也可见于Sjögren综合征及一些有严重全身性疾病的患者。ChronicCariesThecariouslesiondevelopsatslowrate.

病变进展慢。Theslowrateallowstimeforpigmentation.Thedecayedtissueisbrown-to-black.龋坏组织呈黑褐色。Thecavitywallsarehardanddry.病变组织较干硬，又称干性龋。Reparativedentinisformed.修复性牙本质可形成。Specialtypeofchroniccaries静止龋(arrestedcaries)Chroniccariesmaybearrestedafterseveralactivephasesbecauseofchangesintheoralenvironment.龋病发展到某一阶段时，由于病变环境发生变化，原有致病条件改变，龋病不再继续进行，损害仍保持原状，这种特殊龋损害称静止龋。Thelesionis“open”,dark,andhard.SecondaryCaries继发龋Secondarycariesoccursafterthetreatmentbecauseofthecariogeneticenvironmentchangesatthejunctionofarestorationandthetooth.Itmayprogressundertherestorationandisuneasytobedetected.Improper

cavity

preparation

The

dentist

wasunabletoremoveallofthedecayedtissueinthetoothbeforeplacingtherestoration.Inadequate

cavity

restoration

Therestorationispoor,andleakymarginsexistbetweentherestorationandtooth.ToothdestructionThe

margins

of

therestorationorthetoothtissuenearthefillingbreakdown.Thecausesareasfollows:Classification2Involvingsitesofthelesion按损害的解剖部位分类pit-and-fissurecaries窝沟龋smooth-surfacecaries平滑面龋root-surfacecaries根面龋linearenamelcaries线形釉质龋患龋率concealedcaries隐匿性龋Pit-and-fissureCaries合面（窝沟龋）Themostsusceptiblesitesaredevelopmentalpitsandfissures.咬合面的点隙沟裂是最好发龋损的部位。Itoccursontheocclusalsurfacesofposteriorteeth,buccalgroovesofthemolars,lingualsurfacesofanteriorteeth.窝沟龋限指后牙咬合面、磨牙颊沟和上前牙舌面的龋损。Theshapeofthepitsandfissurescontributestotheirhighsusceptibilitytocaries.窝沟的形态与龋病发生发展密切相关。Thelongnarroworificeisdifficultforself-cleaning.窄而深的窝沟缺少自洁作用，对龋病更具敏感性。Theenamelcariesoriginatesatthelateralpartofapitorfissure.窝沟龋首先在侧壁产生。Demineralizationfollowsthedirectionoftheenamelrods.Afteritgetstothedentin,thelesionspreadsalongtheDEJ.龋损沿釉柱方向发展而加深，达到牙本质，然后沿釉牙本质界扩散。Thelesiongoesontopenetratethedentinalongthedentinaltubules.牙本质龋顺牙本质小管方向继续侵入。Thecavityofpit-andfissurecariesisformedlikeaflack.

Theentrysitemayappearsmall.窝沟龋呈口小底大的烧瓶样龋洞，开口小时，窝沟处釉质帮忙无明显破坏，形成潜行性龋(underminedcaries)。Smooth-surfaceCaries平滑面龋Thedentalplaqueusuallydevelopsonthesmoothsurfacesthatarenearthegumorunderproximalcontacts.牙菌斑通常堆积于光滑面接近牙龈的颈部或者邻面触点下方。因此，平滑面龋可进一步分为邻面龋和颈部龋。proximalcariesCervicalcariesRoot-surfaceCaries根面龋Rootsurfacecariesoccursinthecementumoftherootthathasbeenexposedtotheoralenvironment.在根部牙骨质发生的龋损称为根面龋。Itisprevalentinolderpatientswithexposedroots.主要发生于牙龈退缩、根面外露的老年人牙列。Itdevelopsrapidlyandshouldbedetectedandtreatedearly.CementumCaries牙骨质龋Thecementumcoveringtherootsurfaceisthin.Itproviedslittleresistancetocariesattack.Thelesionsprogressrapidly.IntactsurfacezoneProcessofthecariouslesionEnamelCaries釉质龋concealedcariesintheocclusalsurfaceDentinCaries牙本质龋concealedcariesintheproximalsurfaceClassification3Accordingtotheseverityofthelesion按病变深度分类superficialcaries浅龋：龋损仅限牙表层。牙冠部的浅龋为釉质龋或早期釉质龋，牙颈部的浅龋为牙骨质龋和（或）牙本质龋。intermediatecaries中龋：龋损进展到牙本质浅层。deepcaries深龋：龋损进展到牙本质中层以下。根据人民卫生出版社《临床诊疗指南•口腔医学分册》DefinitionDiagnosticTechniquesAskingthepatient问诊Visualinspection视诊Tactileinspection(Exploration)探诊Thermaltest(Pulpvitalitytest)温度刺激试验Dentalradiographs(X-rayexamination)X线检查Specialinspection

transillumination(透照)ClinicalTechniquesPatientswithsuperficialcariesusuallyhavenosymptoms.Itmaybefoundduringaroutinedentalcheckupbeforethepatientisawareofaproblem.whenthedecayedcavitygetstothemiddlelayerofdentine,patientsmayfeelsensitivetohotandcoldliquidsorhavelocalizeddiscomfortaftereatingverysweetfoods.Adeepcavitymaycauseannoyingimpactionofsmallfoodpieces.1.Askingthepatient2.Visualinspection

Tools:adentalmirroranairsyringeLargecariouslesionsareoftenapparenttothenakedeyes.Concealedcariouslesionsaredifficulttoidentify.ColourchangesTheremaybeachalkywhitespotonthetoothwithsmooth-surfaceenamelcaries.Whenthepigmentgoesintothelesion,toothsurfacesbecomebrownorblackatthepitandfissuresitesoronthedecayedcavitysurfaces.3.Tactileinspectionorexploration

Wecancheckforsmallorinitialdecaybygentlyruningtheexplorertipoverallthecrownoftheteeth.Duringtheinspection,weneedtoexam:

textureofthedecayedtooth----softdepthofthecavitysensitivityofthepulp.Wecanfindsomeunderminedorsmallcariesbyexploration.Visualexaminationoftheunderminedcarioustoothwouldshowtheenamelintactorminimallyperforated.Thetipoftheexplorercangetintothepitandfissure.Theunderminedcavitywillbevisiblebyradiograph.Theexplorersuddenly"stops"or"hangsup"inthetooth.4.Thermaltest

Thepatientwouldfeelpainparticularlyaftertakinghot,orcoldfoodsanddrinks.TotestthepulpvitalityColdstimulus:coldwater,icebarHotstimulus:heatedgutta-perchabarElectricaltestofthepulpvitality5.DentalradiographsDentalradiographsmaybetakentoconfirmthepresenceandextentofthedecay.Dentalradiographsmayshowsomecavitiesbeforetheyarevisibletotheeyes.Radiographscouldhelpustofindouttheunder-mineddeepcariouslesions.6.TransilluminationFrontteethmaybeinspectedfordecaybyshiningalightfrombehindthetooth.Thismethodiscalledtransillumination.Areasofdecay,especiallybetweentheteeth,willappearasnoticeableshadowswhenteetharetransilluminated.ManifestationofDentalCariesClinicalManifestationSymptomPhysicalexaminationSpecialinspectionVisualandtactileinspectionThermaltestPulpalelectricaltestTodeterminethelesiontissuechangesofcolor,outline,andtextureSomeinstrumentsareneeded.Dentalradiographsisnecessary.ManifestationoftheSuperficialCariesPatientswithsuperficialcariesusuallyhavenosymptoms.患者一般无主观症状。Theinvolvingpitandfissureisdarkcausedbypigmentation.窝沟龋的病变部位色泽变黑。Theremaybeachalkywhitespotonthesmoothsurface.光滑牙面呈白垩色斑，时间延长会变成黄褐色。Thelesionsurfaceisrough.探诊有粗糙感。Themanifestationofthesuperficiallesionatthecervicalpartisthesameastheintermediatecaries.牙颈部的浅龋症状类似中龋，可能有温度刺激敏感。Specialinspectionsmaybeneeded.邻面浅龋不易察觉，有些龋损需特殊检查。ManifestationoftheIntermediateCariesThecariouscavityisformed.有明显龋洞形成。Somepatientsmayfeelsensitivetohotandcoldliquidsorhavelocalizeddiscomfortaftereatingsweetoracidicfoods.患者对冷热酸痛饮食敏感，冷刺激尤为显著。Thecariouslesionscouldbewetordry.ManifestationoftheDeepCariesAdeepdefectinthetoothisformed.