牙髓病的治疗精品文稿.ppt

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1、牙髓病的治疗第1 页，本讲稿共48 页Principle and Planning 治疗原则和治疗计划第2 页，本讲稿共48 页Treatment Principle 治疗原则1 1、Preserving Vital Pulp Preserving Vital Pulp 保存活髓 保存活髓 2 2、Preserving Offending Tooth Preserving Offending Tooth 保存患牙 保存患牙 第3 页，本讲稿共48 页Treatment Planning 治疗计划n n Emergency Endodontic Treatment 缓解疼痛，控制急性症状 缓解疼

2、痛，控制急性症状n n Examination&Routine Treatment 全面检查，常规治疗全面检查，常规治疗第4 页，本讲稿共48 页Case Analysis 病 例 选 择Basis for Successful Endodontic Basis for Successful Endodonticn n Medical 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 n Dental History 患牙状态患牙状态 尽可能保存患牙尽可能保存患牙第5 页，本讲稿共48 页Infection Control 感染的控制（A

3、septic Technique 无菌技术）n n Isolating the Operative Field 术区隔离 术区隔离n n Sterilizing the Instrument 手机灭菌、器械消毒和灭菌 手机灭菌、器械消毒和灭菌第6 页，本讲稿共48 页Absorbents 隔 湿Cotton rollsCotton rolls第7 页，本讲稿共48 页Rubber Dam 橡 皮 障第8 页，本讲稿共48 页Suction 吸 唾 器Saliva evacuator Saliva evacuatorSaliva ejectors Saliva ejectors第9 页，本讲稿共

4、48 页Pain Control 无痛技术n n Local Anesthesia 局部麻醉法 局部麻醉法2 2 Lidocaine Lidocaine Epinephrine Epinephrine第10 页，本讲稿共48 页Local Anesthesia Techniquesn nLocal infiltration anesthesiaLocal infiltration anesthesia 局部浸润麻醉（常用）局部浸润麻醉（常用）n nBlock anesthesiaBlock anesthesia 阻滞麻醉（常用）阻滞麻醉（常用）n nIntraligamentary anest

5、hesiaIntraligamentary anesthesia 牙周膜内注射 牙周膜内注射n n Intrapulpal anesthesia 牙髓内注射 牙髓内注射第11 页，本讲稿共48 页 Treatment Methods 治疗方法(P.203)n n 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）第12 页，本讲稿共48 页盖髓术 Pulp Capping Pulp capping is defined as ulp capping is defined as“endodontic treatment endodonti

6、c treatment designed to maintain the vitality of the endodontium designed to maintain the vitality of the endodontium”.覆盖使牙髓病变转归的制剂以保护牙髓，消除病变，保存活髓第13 页，本讲稿共48 页盖髓术 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 n Indirect Indirect Pulp Capping Pulp Capping（间接盖髓术

7、）（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 第14 页，本讲稿共48 页Drugs in Pulp Capping and Pulpotomy 常用盖髓剂n nCalcium Hydroxide Calcium Hydroxide 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 n Dycal: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n n Calvital:Calvital:为非可硬性氢氧化钙制剂 为非可硬性氢氧化钙制剂Antibacterial acti

8、vity Antibacterial activity 中和炎症所产生的酸性产物 中和炎症所产生的酸性产物Activate AKP,promote dentin formationActivate AKP,promote dentin formation 激 激活碱性磷酸酶，促进修复性牙本质形成 活碱性磷酸酶，促进修复性牙本质形成第15 页，本讲稿共48 页Remember!These calcium ions present in the dentin bridge come from the systemic circulation,not from the calcium hydroxi

9、de 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第16 页，本讲稿共48 页Other Drugs 其它盖髓剂n n Zinc 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 Glucocoticoids&Antibiotics 糖皮质激素及抗生素 糖皮质激素及抗生素n nHydroxyapatite Hydroxyapatite 羟基磷灰石 羟基磷灰石、BBMPMP 骨形成蛋白 骨形成蛋白 Mineral Trioxide Aggregate(MTA)Minera

10、l Trioxide Aggregate(MTA)第17 页，本讲稿共48 页Direct Pulp Capping 直接盖髓术Pulp capping implies placing the dressing directly onto the pulp exposure.Pulp capping implies placing the dressing directly onto the pulp exposure.第18 页，本讲稿共48 页原 理 用盖髓剂覆盖在露髓创面上，消除炎症和感染，保护牙髓组织，使其恢复健康。第19 页，本讲稿共48 页Indications 适应证1.1.考虑

11、病人年龄 年轻恒牙根尖孔尚未形成2.2.考虑病变程度 恒牙牙髓有无感染、牙髓病变早期阶段第20 页，本讲稿共48 页Contraindication 禁忌证n n 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第21 页，本讲稿共48 页Direct Pulp CappingFor a direct pulp capping For a direct pulp capping procedure,a calcium hydroxide procedure,a calcium hydroxide lining material is placed on the lining materi

12、al is placed on the exposed pulpal tissue and a exposed pulpal tissue and a small amount of surrounding small amount of surrounding dentin.A sealing liner and/or a dentin.A sealing liner and/or a sealing restoration is then placed sealing restoration is then placed to seal out bacteria and their by-

13、to seal out bacteria and their by-products.products.第22 页，本讲稿共48 页Factors that affect outcome of pulp capping or pulpotomy 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 第23 页，本讲稿共48 页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

14、1mmmm行活髓切断术保存活髓行活髓切断术保存活髓第24 页，本讲稿共48 页Local Factors 局部因素22）Location of the exposure Location of the exposure 露髓孔的位置露髓孔的位置颈部龋预后差（轴壁牙本质钙化桥阻颈部龋预后差（轴壁牙本质钙化桥阻断冠髓血供）断冠髓血供）第25 页，本讲稿共48 页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第26 页，本讲稿共48 页Local Factors 局部因素局部因素4）Discouraged for

15、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 的范围内第27 页，本讲稿共48 页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，不能修复第28 页，本讲稿共48 页Local Factors 局部因素6）Periodontally involved teeth 牙周疾患的牙齿盖髓效果差第29 页，本讲稿共48 页Local Factors 局部因素7）Crown and bridge 冠桥修复的基牙为禁忌症第30 页，本讲稿共48 页S

16、ystemic Factors 全身因素n n 干扰牙髓组织的修复 第31 页，本讲稿共48 页Prognosis and Conversion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 个月左右）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 失败第32 页，本讲稿共48 页Prognosis and Conversion预后和转归n n Reported pro

17、gnosis 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髓切断术第33 页，本讲稿共48 页Follow-up 定期复查判断疗效n n 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.第34 页，本讲稿共48 页Indirect Pulp Capping 间接盖髓术（P.206）第35 页，本讲稿共48

18、页原 理 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降，Ca(OH)2可维持局部的碱性环境，有利于修复性牙本质的形成。第36 页，本讲稿共48 页Indication 适应证 n nDeep carious lesionDeep carious lesion深龋保存去龋净未见穿髓、外伤深龋保存去龋净未见穿髓、外伤造成的近髓患牙造成的近髓患牙n n可复性牙髓炎可复性牙髓炎n n诊断性治疗：诊断性治疗：has no history of spontaneous pain has no history of spontaneous pain and respond nor

19、mally to vitality testsand respond normally to vitality tests无明显自发无明显自发痛的慢性牙髓炎和可复性牙髓炎的鉴别痛的慢性牙髓炎和可复性牙髓炎的鉴别第37 页，本讲稿共48 页Indirect Pulp CappingIn an indirect pulp capping procedure,In an indirect pulp capping procedure,demineralized dentin is removed in the demineralized dentin is removed in the periph

20、ery of the preparation,but a small periphery of the preparation,but a small amount of demineralized dentin is left amount of demineralized dentin is left immediately over the area of the pulp.A immediately over the area of the pulp.A calcium hydroxide lining material is placed calcium hydroxide lini

21、ng material is placed to cover the remaining demineralized to cover the remaining demineralized dentin.A sealing liner and/or a sealing dentin.A sealing liner and/or a sealing restoration is then placed to seal out restoration is then placed to seal out bacteria and their by-products.bacteria and th

22、eir by-products.第38 页，本讲稿共48 页Procedure1.Isolation2.Preparation3.Lining4.Restoration第39 页，本讲稿共48 页Pulpotomy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 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 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 hea

23、lthy pulp.第40 页，本讲稿共48 页Indication 适应证 n n外伤性露髓外伤性露髓n n 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（0.5 0.5mmmm），破坏髓室壁、髓室），破坏髓室壁、髓室顶者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第41 页，本讲稿共48 页Follow-up 定期复查判断疗效n n 术后 术后2 2 4 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、牙髓切断术后潜在的 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，故一旦根尖孔发育完成，并发症，

24、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 即行常规根管治疗术第42 页，本讲稿共48 页Emergency treatment 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 coron

25、al and middle portions of the Debride the coronal and middle portions of the root canal with k-files,Hedstrom files,or root canal with k-files,Hedstrom files,or broaches,and use copious NaOCl irrigation,broaches,and use copious NaOCl irrigation,making sure not to penetrate the apical 2 to 3 making s

26、ure not to penetrate the apical 2 to 3 mm of the canal.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 This plan of action may be undert

27、aken depending on the time available for the emergency care:available for the emergency care:第43 页，本讲稿共48 页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 第44 页，

28、本讲稿共48 页Summary of Treatment of Dental Painn n Periodontal(apical)pain-acute exacerbation of chronic lesion Periodontal(apical)pain-acute exacerbation of chronic lesionNo obvious swelling No obvious swelling（acute apical periodontitis acute apical periodontitis）1.Debridement 1.Debridement2.RCT a.s.a

29、.p.2.RCT a.s.a.p.Local swelling Local swelling（acute apical alveolar abscess acute apical alveolar abscess）1.Debridement to allow maximum drainage 1.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

30、 and Local swelling and“cellulitis cellulitis”1.Treatment as above 1.Treatment as above2.Antibiotic therapy 2.Antibiotic therapy3.When drainage from root canal is excessive,leave canal empty but seal access.3.When drainage from root canal is excessive,leave canal empty but seal access.Review within

31、48 hours Review within 48 hours4.Irrigate with copious amount of sodium hypochlorite irrigation 4.Irrigate with copious amount of sodium hypochlorite irrigation5.RCT a.s.a.p.5.RCT a.s.a.p.第45 页，本讲稿共48 页Emergency Treatmentn n 确诊后给予正确的应急处理第46 页，本讲稿共48 页Emergency Treatmentn n 手固定患牙减轻疼痛，尽量减少钻磨震动第47 页，本讲稿共48 页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第48 页，本讲稿共48 页