同济大牙体牙髓病学教案08牙髓尖周病

同济大学口腔医学院讲义编号：课程名称牙体牙髓病学授课日期09-03-25学时2授课章节或题目牙髓病、根尖周病的分类、临床表现及诊断授课教师赵守亮技术职称教授教师资格证号专业年级2006级口腔本科授课方式理论（2）；实验(习)：（）授课内容方法、手段、时间目的和要求：掌握牙髓病的临床分类掌握可复性牙髓炎的临床表现和诊断掌握不可复性牙髓炎的临床表现和诊断掌握牙髓坏死、钙化和牙内吸收的临床表现和诊断了解牙髓病的组织学分类授课内容：EndodontologyEndodonticsPulpdiseasesPulpitis牙髓组织的解剖生理特点硬组织包绕，仅有根尖孔与外界相通疏松而娇嫩的结缔组织血运丰富，血管壁薄自身修复能力有限增龄性变化一、牙髓病分类组织学分类临床分类牙髓充血可复性牙髓炎急性牙髓炎不可复性牙髓炎慢性牙髓炎 急性牙髓炎慢性牙髓炎逆行性牙髓炎牙髓坏死和坏疽牙髓坏死牙髓退变牙髓钙化髓石弥漫性钙化牙内吸收牙内吸收二、临床表现和诊断可复性牙髓炎（ReversiblePulpitis）【临床表现】症状：刺激痛（瞬间）无自发痛（史）检查：近髓腔牙体组织缺损／深牙周袋温度试验一过性敏感【诊断要点】温度刺激一过性敏感无自发痛（史）严重的牙体组织缺损／深牙周袋电活力敏感【鉴别诊断】深龋（龋洞内刺激一过性敏感）不可复性牙髓炎牙本质过敏症（对机械、化学刺激敏感）不可复性牙髓炎（IrreversiblePulpitis）急性牙髓炎慢性牙髓炎残髓炎逆行性牙髓炎急性牙髓炎（AcutePulpitis）原发性急性牙髓炎（一般无症状）慢性牙髓炎急性发作（多见）【临床表现】症状：自发痛：突发性、间歇性、不定位性（锐性、跳动性，间歇性→持续性疼痛）放散性疼痛（三叉神经分布的区域）刺激后痛加剧（早期冷刺激、晚期热刺激）检查：近髓牙体组织缺损／修复体／深牙周袋探诊剧痛（穿髓孔）温度试验－－激发痛持续时间长电活力测试异常（早期敏感，晚期迟钝）轻度叩痛（晚期）【诊断要点】典型的疼痛症状严重的牙体或牙周组织损害牙髓活力测试患牙的确定病史患侧／对侧活力试验X线片封闭慢性牙髓炎（ChronicPulpitis）【临床表现】长期激发痛、自发痛或自发痛史

未穿髓--慢性闭锁性牙髓炎

已穿髓--慢性开放性牙髓炎

溃疡性、增生性（息肉）【诊断要点】患牙有深龋、重度缺损或牙周病等激发痛(延长)、自发痛或自发痛史X线片可有异常改变（膜腔增宽、硬板破损）己穿髓但有活力【鉴别诊断】深龋（一过性刺激痛，无自发痛）可复性牙髓炎（无自发痛史，一过性刺激痛）干槽症（拔牙史，长时间不愈合的拔牙创口）残髓炎（ResidualPulpitis）【临床表现】症状：与慢性牙髓炎相似检查：作过牙髓治疗根管深部探痛【诊断要点】牙髓治疗史牙髓炎表现根管深部探痛逆行性牙髓炎（RetrogradePulpitis）【临床表现】症状：与急性牙髓炎／慢性牙髓炎相似牙周炎（牙松动、咬合痛）检查：深的牙周袋，牙齿松动无严重的牙体组织缺损叩痛，叩诊浊音X线片显示广泛的牙周组织破坏【诊断要点】长期的牙周炎病史，严重的牙周炎表现牙髓炎症状无严重的牙体组织缺损牙髓坏死（PulpNecrosis）【临床表现】症状：一般无症状，检查：可见牙冠变色有／无牙体、牙周组织疾患牙髓无活力X线片显示根尖周影像无明显异常【诊断要点】无自觉症状牙冠变色牙髓无活力X线片根尖周组织无异常【鉴别诊断】慢性根尖周炎X线片根尖周影像密度减低窦道口牙髓钙化（PulpCalcification）【临床表现】症状：一般无症状个别出现自发痛检查：X线片显示髓腔内阻射物【诊断要点】X线片显示髓腔内阻射物需排除其他原因，并且牙髓治疗后疼痛消失【鉴别诊断】三叉神经痛扳机点，卡马西平（特效）牙内吸收（InternalResorption）【临床表现】症状：一般无症状少数有自发痛检查：牙冠、颈部粉红色透色区X线片显示髓腔内不规则透射区【诊断要点】主要依据X线片的表现ReversiblePulpitisIsamild-to-moderateinflammatoryconditionofthepulpcausedbynoxiousstimuliinwhichthepulpiscapableofreturningtotheuninflamedstatefollowingremovalofthestimuli.Painofbriefdurationmaybeproducedbythermalstimuliinthereversibleinflamedpulpbutthepainsubsidesassoonasthestimulusisremoved.SymptomsIscharacterizedbysharppainlastingbutamoment.Itismoreoftenbroughtonbycoldthanhotfoodorbeveragesandbycoldair.Itdoesnotoccurspontaneouslyanddoesnotcontinuewhenthecausehasbeenremoved.Diagnosissymptoms+clinicaltestsIrreversiblePulpitisIsapersistentinflammatoryconditionofthepulpcausedbyanoxiousstimulus.Acuteirreversiblepulpitisexhibitspainusuallycausedbyhotorcoldstimulus,orpainthatoccursspontaneously.Thepainpersistsforseveralminutestohours,lingeringafterremovalofthethermalstimulus.SymptomsAparoxysmofpainmaybecausedbytemperaturechanges,sweetoracidfoodstuffs,pressureandrecumbency.Thepainoftencontinueswhenthecausehasbeenremoved,anditmaycomeandgospontaneouslywithoutapparentcause.Thepainissevere,andmayrefertoadjacentteeth,thetempleortheear.DiagnosisSymptoms+ClinicalinspectionandtestsDeepcavityextendingtothepulpThermaltestmayelicitpainthatpersistsafterremovalofthestimulusTheelectricpulptestinducesaresponsewithamarkedvariationincurrentfromthenormalDifferentialDiagnosisReversible:PainproducedbythermalstimulusdisappearsassoonasthestimulusisremovedIrreversible:Thepainlingersafterthestimulusisremoved,oritcanoccurspontaneouslyNecrosisofPulpIsdeathofthepulp.Itmaybepartialortotal,dependingonwhetherpartofortheentirepulpisinvolved.SymptomsAnotherwisenormaltoothwithanecroticpulpcausesnopainfulsymptoms.Frequently,discolorationofthetoothisthefirstindicationthatthepulpisdeadDiagnosisDiscolorationofthetoothNoresponsetostimulusPulpCalcificationPartofthepulptissueisreplacedbycalcificmaterial.Thiscalcificationmayoccureitherwithinthepulpchamberorrootcanal.InternalResorptionIsanidiopathicsloworfastprogressiveresorptiveprocessoccurringinthedentinofthepulpchamberorrootcanalsofteeth.SymptomsInternalresorptionintherootofatoothisasymptomatic.Inthecrownofthetooth,internalresorptionmaybemanifestedasareddishareacalled“pinkspot”.Thepulphasbeendescribedbothasahighlyresistantorganandasanorganwithlittleresistantorrecuperatingability.Thevariabilityhasledtotheremarkthat“Somepulpswilldieifyoulookcrosslyatthem,whileotherscan’tbekilledwithanax”大课讲授，图片，临床典型病例分析3min相关词汇的区别词头、词尾和词干的用法复习：（5min）牙髓组织的解剖生理特点主要强化与牙髓组织疾病的发生、发展和预后的关系，突出髓腔高压的形成和临床意义5min重点临床分类5min重点强化诊断要点13min选用两个典型病例（1个急诊病例，1个急性牙髓炎后期）重点讲述临床表现特征补充：临床上用于患牙确定的5种方法8min强调诊断要点6min说明不同部位的残髓临床表现不同（第1个学时结束）5min解释逆行性的含义，5min说明诊断比较容易，主要依据牙冠变色和牙髓活力丧失（临床照片）5min必须排除其他原因才能确诊(选1个临床病例)（X线片）3min比较少见（X线片）牙髓病小结5min专业外语：22min强调：Painofbriefduration，painsubsidesassoonasthestimulusisremoved.强调:doesnotoccurspontaneously