牙髓病的治疗.ppt

牙髓病的治疗 Still waters run deep.流静水深流静水深,人静心深人静心深 Where there is life,there is hope。有生命必有希望。有生命必有希望Principle and Planning 治疗原则和治疗计划治疗原则和治疗计划Treatment Principle 治疗原则治疗原则1 1、Preserving Vital PulpPreserving Vital Pulp 保存活髓保存活髓 2 2、Preserving Offending ToothPreserving Offending Tooth 保存患牙保存患牙 Treatment Planning 治疗计划治疗计划n nEmergency Endodontic Treatment 缓解疼痛，控制急性症状缓解疼痛，控制急性症状n nExamination&Routine Treatment 全面检查，常规治疗全面检查，常规治疗Case Analysis 病病 例例 选选 择择Basis for Successful EndodonticBasis for Successful Endodonticn nMedical History 患者状态患者状态 适用于任何年龄，无绝对的全身适用于任何年龄，无绝对的全身禁忌证禁忌证n nDental History 患牙状态患牙状态 尽可能保存患牙尽可能保存患牙Infection Control感染的控制（Aseptic Technique无菌技术）n nIsolating the Operative Field 术区隔离术区隔离n nSterilizing the Instrument 手机灭菌、器械消毒和灭菌手机灭菌、器械消毒和灭菌Absorbents 隔隔 湿湿Cotton rollsRubber Dam 橡橡 皮皮 障障Suction 吸吸 唾唾 器器Saliva evacuatorSaliva ejectorsPain Control 无痛技术n nLocal Anesthesia 局部麻醉法局部麻醉法局部麻醉法局部麻醉法2 2 Lidocaine LidocaineEpinephrineEpinephrineLocal Anesthesia Techniquesn nLocal infiltration anesthesia 局部浸润麻醉局部浸润麻醉局部浸润麻醉局部浸润麻醉（常用）常用）常用）常用）n nBlock anesthesia 阻滞麻醉阻滞麻醉阻滞麻醉阻滞麻醉（常用）常用）常用）常用）n nIntraligamentary anesthesia 牙周膜内注射牙周膜内注射牙周膜内注射牙周膜内注射n nIntrapulpal anesthesia 牙髓内注射牙髓内注射牙髓内注射牙髓内注射 Treatment Methods 治疗方法治疗方法(P.203)n n保存活髓保存活髓 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）盖髓术盖髓术 Pulp CappingPulp capping is defined as“endodontic ulp capping is defined as“endodontic treatment designed to maintain the vitality of treatment designed to maintain the vitality of the endodontium”.the endodontium”.n n覆盖使牙髓病变转归的制剂以保护牙髓，消除病变，保存活髓盖髓术盖髓术 Pulp Cappingn nDirectDirect Pulp Capping Pulp Capping（直接盖髓术）（直接盖髓术）覆盖已暴露的牙髓覆盖已暴露的牙髓n nIndirectIndirect Pulp Capping Pulp Capping （间接盖髓术）（间接盖髓术）覆盖接近牙髓的牙本质覆盖接近牙髓的牙本质 Drugs in Pulp Capping and Pulpotomy 常用盖髓剂常用盖髓剂n nCalcium Hydroxide Calcium Hydroxide 氢氧化钙氢氧化钙(highly(highly alkalinealkaline强碱性强碱性)最具疗效的盖髓剂之一最具疗效的盖髓剂之一n nDycal:Dycal:可硬性氢氧化钙制剂，可作为次基材料可硬性氢氧化钙制剂，可作为次基材料可硬性氢氧化钙制剂，可作为次基材料可硬性氢氧化钙制剂，可作为次基材料n nCalvital:Calvital:为非可硬性氢氧化钙制剂为非可硬性氢氧化钙制剂为非可硬性氢氧化钙制剂为非可硬性氢氧化钙制剂Antibacterial activity中和炎症所产生的酸中和炎症所产生的酸性产物性产物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n nZinc Oxide-eugenol 氧化锌丁香油糊剂（多用于间接盖髓）氧化锌丁香油糊剂（多用于间接盖髓）n nGlucocoticoids&Antibiotics 糖皮质激素及抗生素糖皮质激素及抗生素n nHydroxyapatite 羟基磷灰石羟基磷灰石、BMP骨形成蛋白骨形成蛋白 Mineral Trioxide Aggregate(MTA)Direct Pulp Capping 直接盖髓术Pulp capping implies placing the dressing directly onto the pulp exposure.原原 理理 用盖髓剂用盖髓剂覆盖在露髓创面上，消除覆盖在露髓创面上，消除炎症和感染，保护牙髓组织，使其恢复炎症和感染，保护牙髓组织，使其恢复健康。健康。Indications 适应证1.考虑病人年龄 年轻恒牙根尖孔尚未形成2.考虑病变程度 恒牙牙髓有无感染、牙髓病变早期阶段Contraindication 禁忌证禁忌证n n有牙痛史的恒牙有牙痛史的恒牙n n有慢性牙髓炎或根尖周炎表现的患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 placed to seal out bacteria and their by-products.Factors that affect outcome of pulp capping or pulpotomy 决定预后的因素决定预后的因素 1.1.Local factors 局部因素2.2.Systemic factors 全身因素3.3.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 露髓孔大小露髓孔大小直径大于直径大于1 1mmmm行活髓切断术保存行活髓切断术保存活髓活髓Local Factors 局部因素2 2）Location of the exposureLocation of the exposure 露髓孔的位置露髓孔的位置颈部龋预后差（轴壁牙本质钙化颈部龋预后差（轴壁牙本质钙化桥阻断冠髓血供）桥阻断冠髓血供）Local Factors 局部因素局部因素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 involved 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n n干扰牙髓组织的修复 Prognosis and Conversion预后和转归预后和转归牙髓组织的转归分为成功和失败两个方面牙髓组织的转归分为成功和失败两个方面n n穿髓孔下修复性牙本质形成，封闭穿髓点穿髓孔下修复性牙本质形成，封闭穿髓点成功（术后成功（术后2 2个月左右）个月左右）n n牙髓组织慢性炎症，出现疼痛症状；牙髓钙化或内吸收牙髓组织慢性炎症，出现疼痛症状；牙髓钙化或内吸收失败失败Prognosis and Conversion预后和转归预后和转归n nReported prognosis is in the range of 80%n n年轻恒牙直接盖髓术后冠髓感染可试行活年轻恒牙直接盖髓术后冠髓感染可试行活髓切断术髓切断术Follow-up 定期复查判断疗效n 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.Indirect Pulp Capping 间接盖髓术 （P.206）原原 理理 窝洞中遗留的少量细菌被盖髓剂覆盖，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及细菌产酸所需的底物被隔绝而大幅度下降，降，Ca(OH)2可维持局部的碱性环境，有可维持局部的碱性环境，有利于修复性牙本质的形成。利于修复性牙本质的形成。Indication 适应证适应证 n nDeep carious lesionDeep carious lesion深龋保存去龋净未见穿髓、深龋保存去龋净未见穿髓、深龋保存去龋净未见穿髓、深龋保存去龋净未见穿髓、外伤造成的近髓患牙外伤造成的近髓患牙外伤造成的近髓患牙外伤造成的近髓患牙n n可复性牙髓炎可复性牙髓炎可复性牙髓炎可复性牙髓炎n n诊断性治疗：诊断性治疗：诊断性治疗：诊断性治疗：has no history of spontaneous has no history of spontaneous pain and respond normally to vitality testspain 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无明显自发痛的慢性牙髓炎和可复性牙髓炎的鉴别无明显自发痛的慢性牙髓炎和可复性牙髓炎的鉴别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 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.RestorationPulpotomy活髓切断术活髓切断术(P.207)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 适应证适应证 n n外伤性露髓外伤性露髓外伤性露髓外伤性露髓n n慢性牙髓炎慢性牙髓炎慢性牙髓炎慢性牙髓炎n n意外穿髓孔较大（意外穿髓孔较大（意外穿髓孔较大（意外穿髓孔较大（0.50.5mmmm），），），），破坏髓室壁、破坏髓室壁、破坏髓室壁、破坏髓室壁、髓室顶者髓室顶者髓室顶者髓室顶者根尖孔发育未完成的年轻恒牙根尖孔发育未完成的年轻恒牙Follow-up 定期复查判断疗效n n术后术后2 24 4年内定期复查年内定期复查n n牙髓坏死、钙化、内吸收是直接盖髓术、牙髓切断牙髓坏死、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，故一旦根尖孔发育完成，即行常规根管治疗术一旦根尖孔发育完成，即行常规根管治疗术Emergency treatment 应急处理应急处理(P.213)1.1.Establish proper access to all canals.Establish proper access to all canals.2.2.Irrigate thoroughly with NaOCl.Irrigate thoroughly with NaOCl.3.3.Debride pulp chamber.Debride pulp chamber.4.4.Debride the coronal and middle portions Debride the coronal and middle portions of the root canal with k-files,Hedstrom of the root canal with k-files,Hedstrom files,or broaches,and use copious NaOCl files,or broaches,and use copious NaOCl irrigation,making sure not to penetrate irrigation,making sure not to penetrate the apical 2 to 3 mm of the canal.the apical 2 to 3 mm of the canal.5.5.Temporarily seal the access opening.Temporarily seal the access opening.6.6.Use analgesics as necessary.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 Painn nPulpal pain-irreversible pulpitisPulpal pain-irreversible pulpitis 1.Access cavity and debridement 1.Access cavity and debridement 2.Adjust 2.Adjust Summary of Treatment of Dental Painn nPeriodontal(apical)pain-acute exacerbation of chronic lesionPeriodontal(apical)pain-acute exacerbation of chronic lesionNo obvious swelling No obvious swelling（acute apical periodontitisacute apical periodontitis）1.Debridement1.Debridement2.RCT a.s.a.p.2.RCT a.s.a.p.Local swelling Local swelling（acute apical alveolar abscessacute apical alveolar abscess）1.Debridement to allow maximum drainage1.Debridement to allow maximum drainage2.Clean canal 2.Clean canal 3.Incise if fluctuant 3.Incise if fluctuant 4.RCT a.s.a.p.4.RCT a.s.a.p.Local swelling and“cellulitis”Local swelling and“cellulitis”1.Treatment as above1.Treatment as above2.Antibiotic therapy2.Antibiotic therapy3.When drainage from root canal is excessive,leave canal empty 3.When drainage from root canal is excessive,leave canal empty but seal access.Review within 48 hoursbut seal access.Review within 48 hours4.Irrigate with copious amount of sodium hypochlorite irrigation4.Irrigate with copious amount of sodium hypochlorite irrigation5.RCT a.s.a.p.5.RCT a.s.a.p.Emergency Treatmentn n 确诊后给予正确的应急处理Emergency Treatmentn n手固定患牙减轻疼痛，尽量减少钻磨震动Incise and Drain the Swelling 切开排脓 确诊和把握切开排脓的时机非常重要