10牙髓病的治療

1、(p.189) 1、preserving vital pulp 保存活髓 2、preserving offending tooth 保存患牙 nemergency endodontic treatment 緩解疼痛，控制急性癥狀nexamination & routine treatment 全面檢查，常規(guī)治療nmedical history 患者狀態(tài) 適用于任何年齡，無(wú)絕對(duì)的全身禁忌證ndental history 患牙狀態(tài) 盡可能保存患牙感染的控制無(wú)菌技術(shù)）nisolating the operative field 術(shù)區(qū)隔離nsterilizing the instrument

2、手機(jī)滅菌、器械消毒和滅菌cotton rolls saliva evacuatorsaliva ejectors 無(wú)痛技術(shù)nlocal anesthesia2 lidocaineepinephrinenlocal infiltration anesthesia nblock anesthesianintraligamentary anesthesianintrapulpal anesthesia(p.203)保存全部生活牙髓pulp capping（蓋髓術(shù)） 保存根部生活牙髓pulpotomy（牙髓切斷術(shù)）pulp capping is defined as “endodontic treat

3、ment designed to maintain the vitality of the endodontium”.n覆蓋使牙髓病變轉(zhuǎn)歸的制劑以保護(hù)牙髓，消除病變，保存活髓 pulp cappingndirect pulp capping（直接蓋髓術(shù)）覆蓋已暴露的牙髓nindirect pulp capping （間接蓋髓術(shù)）覆蓋接近牙髓的牙本質(zhì) ncalcium hydroxide (highly alkaline強(qiáng)堿性) 最具療效的蓋髓劑之一antibacterial activity中和炎癥所產(chǎn)生的酸中和炎癥所產(chǎn)生的酸性產(chǎn)物性產(chǎn)物activate akp, promote dentin

4、 formation激活堿性磷酸酶，促進(jìn)修復(fù)性牙本質(zhì)形成激活堿性磷酸酶，促進(jìn)修復(fù)性牙本質(zhì)形成remember! these calcium ions present in the dentin bridge come from the systemic circulation,not from the calcium hydroxide you used. 修復(fù)過(guò)程中形成的牙本質(zhì)橋中的鈣離子是來(lái)自體循環(huán)其它蓋髓劑nzinc oxide-eugenol 氧化鋅丁香油糊劑（多用于間接蓋髓）nglucocoticoids & antibiotics 糖皮質(zhì)激素及抗生素nhydroxyapat

5、ite 羥基磷灰石、bmp骨形成蛋白 mineral trioxide aggregate (mta)直接蓋髓術(shù)pulp capping implies placing the dressing directly onto the pulp exposure.原原 理理 用蓋髓劑用蓋髓劑覆蓋在露髓創(chuàng)面上，消除覆蓋在露髓創(chuàng)面上，消除炎癥和感染，保護(hù)牙髓組織，使其恢炎癥和感染，保護(hù)牙髓組織，使其恢復(fù)健康。復(fù)健康。 適應(yīng)證1. 考慮病人年齡 年輕恒牙根尖孔尚未形成2. 考慮病變程度 恒牙牙髓有無(wú)感染、牙髓病變?cè)缙陔A段for a direct pulp capping procedure, a cal

6、cium 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.局部因素1）the size of the exposure 露髓孔大小直徑大于1mm行活髓切斷術(shù)保存活髓局部因素2）location of the exposure 露

7、髓孔的位置頸部齲預(yù)后差（軸壁牙本質(zhì)鈣化橋阻斷冠髓血供）局部因素3）periods of exposure 牙髓暴露的時(shí)間越長(zhǎng)，牙髓發(fā)生炎癥的可能性越大局部因素4） discouraged for carious pulp exposures 牙髓暴露的類(lèi)型因齲病露髓的牙齒由于細(xì)菌感染不提倡蓋髓 外傷性露髓炎癥多局限在距牙髓表面2mm的范圍內(nèi)局部因素5） marginal leakage 邊緣滲漏，牙髓炎癥將持續(xù)存在，不能修復(fù)局部因素6） periodontally involved teeth 牙周疾患的牙齒蓋髓效果差局部因素7） crown and bridge 冠橋修復(fù)的基牙為禁忌癥 全身

8、因素n干擾牙髓組織的修復(fù) 牙髓組織的轉(zhuǎn)歸分為成功和失敗兩個(gè)方面n穿髓孔下修復(fù)性牙本質(zhì)形成，封閉穿髓點(diǎn)成功（術(shù)后2個(gè)月左右）n牙髓組織慢性炎癥，出現(xiàn)疼痛癥狀；牙髓鈣化或內(nèi)吸收失敗nreported prognosis is in the range of 80%定期復(fù)查判斷療效nelectric pulp testing, thermal testing, palpation tests, and percussion tests should be carried out at 3 weeks;3,6, and 12 months; and yearly thereafter.間接蓋髓術(shù) （p

9、.206）原原 理理 窩洞中遺留的少量細(xì)菌被蓋髓劑覆蓋，窩洞中遺留的少量細(xì)菌被蓋髓劑覆蓋，及細(xì)菌產(chǎn)酸所需的底物被隔絕而大幅度下及細(xì)菌產(chǎn)酸所需的底物被隔絕而大幅度下降，降，ca(oh)2可維持局部的堿性環(huán)境，有可維持局部的堿性環(huán)境，有利于修復(fù)性牙本質(zhì)的形成。利于修復(fù)性牙本質(zhì)的形成。ndeep carious lesionhas no history of spontaneous pain and respond normally to vitality testsin an indirect pulp capping procedure, demineralized dentin is remo

10、ved 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 bacter

11、ia and their by-products. 1.isolation2.preparation3.lining4.restorationpulpotomy活髓切斷術(shù)活髓切斷術(shù) 是通過(guò)臨床征象確定切除組織的深度，去除有病變的冠髓，以蓋髓劑覆蓋于牙髓斷面，保存未感染根髓的治療方法 pulpotomy implies the removal of coronal pulp tissue to the level of healthy pulp.定期復(fù)查判斷療效n術(shù)后24年內(nèi)定期復(fù)查n牙髓壞死、鈣化、內(nèi)吸收是直接蓋髓術(shù)、牙髓切斷術(shù)后潛在的并發(fā)癥，影響日后的樁釘固位修復(fù)，故一旦根尖孔發(fā)育完成，即行

12、常規(guī)根管治療術(shù) 1.establish proper access to all canals.2.irrigate thoroughly with naocl.3.debride pulp chamber.4.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 ca

13、nal.5.temporarily seal the access opening.6.use analgesics as necessary.this plan of action may be undertaken depending on the time available for the emergency care:npulpal pain-irreversible pulpitis 1.access cavity and debridement 2.adjust nperiodontal (apical) pain-acute exacerbation of chronic lesion1. debridement2. rct a.s.a.p.1. debridement to allow maximum drainage2. clean canal 3. incise if fluctuant 4. rct a.s.a.p.1. treatment as above2. antibiotic therapy3. when drainage from ro