牙髓病和根尖周病診療概述

1、牙髓病和根尖周病診療概述Principle and Planning 治療原則和治療計劃Treatment Principle 治療原則1、Preserving Vital Pulp 保存活髓 2、Preserving Offending Tooth 保存患牙 Treatment Planning 治療計劃Emergency Endodontic Treatment 緩解疼痛，控制急性癥狀Examination & Routine Treatment 全面檢查，常規(guī)治療Case Analysis 病 例 選 擇Basis for Successful EndodonticMedical His

2、tory 患者狀態(tài) 適用于任何年齡，無絕對的全身禁忌證Dental History 患牙狀態(tài) 盡可能保存患牙Infection Control感染的控制（Aseptic Technique無菌技術(shù)）Isolating the Operative Field 術(shù)區(qū)隔離Sterilizing the Instrument 手機滅菌、器械消毒和滅菌Absorbents 隔 濕Cotton rollsRubber Dam 橡 皮 障Suction 吸 唾 器Saliva evacuatorSaliva ejectorsPain Control 無痛技術(shù)Local Anesthesia 局部麻醉法2 L

3、idocaineEpinephrineLocal Anesthesia TechniquesLocal infiltration anesthesia 局部浸潤麻醉（常用）Block anesthesia 阻滯麻醉（常用）Intraligamentary anesthesia 牙周膜內(nèi)注射Intrapulpal anesthesia 牙髓內(nèi)注射 Treatment Methods 治療方法 (P.203)保存活髓 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)） 蓋髓術(shù) Pulp CappingPulp capping is defined

4、as “endodontic treatment designed to maintain the vitality of the endodontium”.覆蓋使牙髓病變轉(zhuǎn)歸的制劑以保護牙髓，消除病變，保存活髓蓋髓術(shù) Pulp CappingDirect Pulp Capping（直接蓋髓術(shù)） 覆蓋已暴露的牙髓Indirect Pulp Capping （間接蓋髓術(shù)） 覆蓋接近牙髓的牙本質(zhì) Drugs in Pulp Capping and Pulpotomy 常用蓋髓劑Calcium Hydroxide 氫氧化鈣 (highly alkaline強堿性) 最具療效的蓋髓劑之一Dycal:可

5、硬性氫氧化鈣制劑，可作為次基材料Calvital:為非可硬性氫氧化鈣制劑Antibacterial activity中和炎癥所產(chǎn)生的酸性產(chǎn)物Activate AKP, promote dentin formation激活堿性磷酸酶，促進修復性牙本質(zhì)形成Remember! These calcium ions present in the dentin bridge come from the systemic circulation,not from the calcium hydroxide you used. 修復過程中形成的牙本質(zhì)橋中的鈣離子是來自體循環(huán)Other Drugs 其它蓋髓劑

6、Zinc Oxide-eugenol 氧化鋅丁香油糊劑（多用于間接蓋髓）Glucocoticoids & Antibiotics 糖皮質(zhì)激素及抗生素Hydroxyapatite 羥基磷灰石、BMP骨形成蛋白 Mineral Trioxide Aggregate (MTA)Direct Pulp Capping 直接蓋髓術(shù)Pulp capping implies placing the dressing directly onto the pulp exposure.原 理 用蓋髓劑覆蓋在露髓創(chuàng)面上，消除炎癥和感染，保護牙髓組織，使其恢復健康。Indications 適應證考慮病人年齡 年輕恒牙

7、根尖孔尚未形成考慮病變程度 恒牙牙髓有無感染、牙髓病變早期階段Contraindication 禁忌證有牙痛史的恒牙有慢性牙髓炎或根尖周炎表現(xiàn)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 決定預后的因素 Local factors 局部因素Systemic factors 全身因素Ages and Status of the Pulp 年齡與牙髓的狀態(tài) Local Factors 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Local Factors 局部因素2）Location of the exposu

9、re 露髓孔的位置頸部齲預后差（軸壁牙本質(zhì)鈣化橋阻斷冠髓血供）Local Factors 局部因素3）Periods of exposure 牙髓暴露的時間越長，牙髓發(fā)生炎癥的可能性越大Local Factors 局部因素4） Discouraged for carious pulp exposures 牙髓暴露的類型因齲病露髓的牙齒由于細菌感染不提倡蓋髓 外傷性露髓炎癥多局限在距牙髓表面2mm的范圍內(nèi)Local Factors 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Local Factors 局部因素6） Periodontally invol

10、ved teeth 牙周疾患的牙齒蓋髓效果差Local Factors 局部因素7） Crown and bridge 冠橋修復的基牙為禁忌癥Systemic Factors 全身因素干擾牙髓組織的修復 Prognosis and Conversion預后和轉(zhuǎn)歸牙髓組織的轉(zhuǎn)歸分為成功和失敗兩個方面穿髓孔下修復性牙本質(zhì)形成，封閉穿髓點成功（術(shù)后2個月左右）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Prognosis and Conversion預后和轉(zhuǎn)歸Reported prognosis is in the range of 80%年輕恒牙直接蓋髓術(shù)后冠髓感染可試行活髓切斷術(shù)Foll

11、ow-up 定期復查判斷療效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 間接蓋髓術(shù) （P.206）原 理 窩洞中遺留的少量細菌被蓋髓劑覆蓋，及細菌產(chǎn)酸所需的底物被隔絕而大幅度下降，Ca(OH)2可維持局部的堿性環(huán)境，有利于修復性牙本質(zhì)的形成。Indication 適應證 Deep cariou

12、s lesion深齲保存去齲凈未見穿髓、外傷造成的近髓患牙可復性牙髓炎診斷性治療：has no history of spontaneous pain and respond normally to vitality tests無明顯自發(fā)痛的慢性牙髓炎和可復性牙髓炎的鑒別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活髓切斷術(shù) (P.207) 是通過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.Indication 適應證 外傷性露髓慢性牙髓炎意外穿髓孔較大（0.5mm），破壞髓室壁、髓室頂者根尖孔發(fā)育未完成的年輕恒牙Follow-up 定期復查判斷療效術(shù)后24年內(nèi)定期復查牙髓壞死、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，故一旦根尖孔

15、發(fā)育完成，即行常規(guī)根管治療術(shù)Emergency treatment 應急處理(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