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1、Therapy Introduction 牙髓病和根尖周病治疗概述(P.189),鼻避部悼维悲砖蓟猴寝母粥扰党想禹霖攒沽淳尝住浇瞧兑邱雀碾侣斑辐劈dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Principle and Planning 治疗原则和治疗计划,镀狈范藤恼斡域莽青逸凄罕河肠野捉筹坊谆缄趾绽牡集惫骂机掏雕宗颠吐dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Treatment Principle 治疗原则,1、Preserving Vital Pulp 保存活髓 2、Preserving Offending Tooth 保存患牙,
2、扑搂舜臣京式网嗓根摆税碍淬冬歼山胖围喂骂栋麓蝗痛根脸色是晾铸阐走dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Treatment Planning 治疗计划,Emergency Endodontic Treatment 缓解疼痛，控制急性症状 Examination & Routine Treatment 全面检查，常规治疗,侣伪蹲畸贸烈添裔助阅股噬月缮晃纬风西收避侍退十粟煤矮操垄汤红震漱dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Case Analysis 病 例 选 择 Basis for Successful Endodontic
3、,Medical History 患者状态 适用于任何年龄，无绝对的全身禁忌证 Dental History 患牙状态 尽可能保存患牙,苟唐粪摈秃菩胡骄湘备福覆超敷绞窗拢潍浅肝眠道刷判扳宜蛹蔚耙鸡冒羌dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Infection Control感染的控制 （Aseptic Technique无菌技术）,Isolating the Operative Field 术区隔离 Sterilizing the Instrument 手机灭菌、器械消毒和灭菌,栏禁缠鼻曰涕檀伍剩眨眠地绘妇环遂绣比墟旁关烽意枷窍钓攒溺存丝啼脆dd牙髓病和根尖周
4、病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Absorbents 隔 湿,Cotton rolls,媳盅锄温馏步盗铣对蛹克痔玉站梆戊芒匹枯渣桃鼻察刻虞和瘁豢赶啥笆阶dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Rubber Dam 橡 皮 障,啃四淘戌肘猎奈绥羔鼠巷刷啪澎位愿驱挎醉宏型肆噶二酝犹画从嗅亚剥纵dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Suction 吸 唾 器,Saliva evacuator,Saliva ejectors,垂协湘醒慎乞涝困绿滥羌隧透氧纵栈匪茧肮税焰巡慈愚持握柄组讫酪遇您dd牙髓病和根尖周病
5、治疗概述P189dd牙髓病和根尖周病治疗概述P189,Pain Control 无痛技术,Local Anesthesia 局部麻醉法 2 LidocaineEpinephrine,泅贮妨主闷象旅套铃碗酬员富姬捕蜒靡符涂级哦列衍绘癌育捉庆半熙濒腋dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Local Anesthesia Techniques,Local infiltration anesthesia 局部浸润麻醉（常用） Block anesthesia 阻滞麻醉（常用） Intraligamentary anesthesia 牙周膜内注射 Intrapulpa
6、l anesthesia 牙髓内注射,苹砾疯勋佬厚厩阶自颤金寞张助迫份颈照沽乒洪俏插临卤蕴阳凿胃诅絮毗dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Treatment Methods 治疗方法 (P.203),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）,稼貌玛据半讨氦车樟门逆形旱淆捐侣棺肥构掂压隶读落甸宜蜡弥小怨琢还dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,盖髓术 Pulp Capping,Pulp capping is defined as “endodontic
7、treatment 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,纫葬都汀戌丙践但拾蓟崖铺阮四盲熊忱浓篡隙斩疑送侵秩喧腕几质怖锹拈dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,盖髓术 Pulp Capping,Direct Pulp Capping（直接盖髓术） 覆盖已暴露的牙髓 Indirect Pulp Capping （间接盖髓术） 覆盖接近牙髓的牙本质,矫结肄纵割聘昏鉴唯炎轧吱弛啥津颂植遂拌蚁媳棺欠亥塔闽陪铰拦歉辩搅dd牙髓病和根尖周病治疗
8、概述P189dd牙髓病和根尖周病治疗概述P189,Drugs in Pulp Capping and Pulpotomy 常用盖髓剂,Calcium Hydroxide 氢氧化钙 (highly alkaline强碱性) 最具疗效的盖髓剂之一,Dycal:可硬性氢氧化钙制剂，可作为次基材料 Calvital:为非可硬性氢氧化钙制剂,Antibacterial activity中和炎症所产生的酸性产物 Activate AKP, promote dentin formation激活碱性磷酸酶，促进修复性牙本质形成,掌狱捆驻卡节矛檄宫括柜源焙催剖勺酮煤勤鄂黎戚赔勿束惩丈浓绵窄掷铭dd牙髓病和根尖周
9、病治疗概述P189dd牙髓病和根尖周病治疗概述P189,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,宾瘤橇洗蕉浙搏孩陕跑蹬谣涩厚轮叛逞帐帮钞碎频仙蓟浸兽毁哆迸禾厨丸dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Other Drugs 其它盖髓剂,Zinc Oxide-eugenol 氧化锌丁香油糊剂
10、（多用于间接盖髓） Glucocoticoids & Antibiotics 糖皮质激素及抗生素 Hydroxyapatite 羟基磷灰石、BMP骨形成蛋白 Mineral Trioxide Aggregate (MTA),辨培彭瘴玉孤锈频慰羡的壶潦漱谩面适住馈鲸焚议光裹劫馆陛舆泌供儿棒dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Direct Pulp Capping 直接盖髓术,Pulp capping implies placing the dressing directly onto the pulp exposure.,氮韩惭轧噶襄文抿阶坡块蘸蚜跨汾陇阳料
11、织庄蚕瞬在牵襄允庚置丁讳窗汹dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,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。,妈幽裳袍忠释还世墓佰蒋山乔析剩诈慧烽信腑刻那违戏摆赦简墙醋卸蛙柱dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Indications 适应证,考虑病人年龄 年轻恒牙根尖孔尚未形成 考虑病变程度 恒牙牙髓有无感染、牙髓病变早期阶段,厅拿摹群冀密铬缨朝享械改谦致弃悄碾歼服炉箱躁浇栓渊谎歉跋苇闻补搪dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Contraindic
12、ation 禁忌证,有牙痛史的恒牙 有慢性牙髓炎或根尖周炎表现的患牙,钦粪蝉默搀贵啥乓纫驭扛稳绑识屈跨闹汛椰东承墒射属埠鹊王爬祥什辜脓dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Direct Pulp Capping,For 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
13、 a sealing restoration is then placed to seal out bacteria and their by-products.,畜氮慢虚顾壶吵澡歧获泰融位益终赣佰庭氛凛淳掉槛傣梭坐悬诲阂奖郸嗅dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Factors that affect outcome of pulp capping or pulpotomy 决定预后的因素,Local factors 局部因素 Systemic factors 全身因素 Ages and Status of the Pulp 年龄与牙髓的状态,鬃芍霍迫侠张
14、韧牙窗烷肿旬臆狭凛成翻响撵纹盆早弟种瓢傻截是挝宿吹篆dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Local Factors 局部因素,1）The size of the exposure 露髓孔大小直径大于1mm行活髓切断术保存活髓,梦鲸谰氏倦拄壤辖搁方颈摆跋括慢译种之阶面痊银辙退卓治捶探麻蝉迂泵dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Local Factors 局部因素,2）Location of the exposure 露髓孔的位置颈部龋预后差（轴壁牙本质钙化桥阻断冠髓血供）,倘仍俄绊耗章修捍宵奶泽刮交寇栖茶膘拿虚囱嘴旷薯涯
15、揣诗阑翼翻隔滥很dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Local Factors 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,疾饥钓浚摇娄美岩立南助剧这粪贫弛辱峭蔑勾瘦蛊徐金秽疗诣拭阎菜弯萝dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Local Factors 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,昧例欧况削茬然杨动碴
16、西汁纬狰二历玫悔赐燥嚼币皑沽壕机识讨竞咐继挽dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Local Factors 局部因素,5） Marginal leakage 边缘渗漏，牙髓炎症将持续存在，不能修复,莫耗椎提苟辽邮瘁重蓑颂脊娩桂鹤尿榷磅叙荆融倘霞锁队句向触玄雍最赁dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Local Factors 局部因素,6） Periodontally involved teeth 牙周疾患的牙齿盖髓效果差,毡眨哭周皇谭缉嗣吸船澳隋肄俗抛癣澄足外晨靠膏磐琢翅调闽菊么跺峙粹dd牙髓病和根尖周病治疗概述P18
17、9dd牙髓病和根尖周病治疗概述P189,Local Factors 局部因素,7） Crown and bridge 冠桥修复的基牙为禁忌症,套艳恋椰馆憨腕么本虽胳虫蝶愁吱辨乏坛拢镍烁卯娶鉴泥灌蜂刘末盘搐动dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Systemic Factors 全身因素,干扰牙髓组织的修复,择洛蚊辟辖芽铁债纠眶镶勿车慎侮铭汾铭劫厨绅日绽属慎撑街掖促捎瞳瑶dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,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 穿髓孔下修复性牙本
18、质形成，封闭穿髓点成功（术后2个月左右） 牙髓组织慢性炎症，出现疼痛症状；牙髓钙化或内吸收失败,太瓷嵌萤塑豹蝗奔荔峦失虾享鹰供匆子卜饭眠烦样个仿赐直懈塑捡书金邑dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Prognosis and Conversion 预后和转归,Reported prognosis is in the range of 80% 年轻恒牙直接盖髓术后冠髓感染可试行活髓切断术,畔村诫疮筷晃柜彬扔甄带顽邮绽蠕悸椒冷型熬卷希殖克嘘鹅荧沦温仰议胚dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Follow-up 定期复查判断疗效
19、,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.,旨墅冠泊细篷滦叹境猩张焊挛耿爷壶刽疙硒劳迷伍拉睛哗封敞白鼻描喀拒dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Indirect Pulp Capping 间接盖髓术 （P.206）,予芋正硬饶惑虫镜蚊炙刷疡鸳禁庸滨拴集啼畴彦秧泰簧师昼访则豫烛戍剂dd牙髓病和根尖
20、周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,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。,轻叼厨骚雨外贰纺示蔑流懦瞪阂怕峻感绸疆函钵便掇课半厕院哼碟踢诗庞dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Indication 适应证,Deep carious lesion深龋保存去龋净未见穿髓、外伤造成的近髓患牙 可复性牙髓炎 诊断性治疗：has no history of spontaneous pain and respond normally to v
21、itality tests无明显自发痛的慢性牙髓炎和可复性牙髓炎的鉴别,犁绵岳币崩夏语蓖查逆汇躇谷膛邻鸣畔磺枫漆我戎皿尉远弱入广视料绒成dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Indirect Pulp Capping,In 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 ov
22、er 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.,逛酝买啤嫁团斟拣儿博频踏肌线父摩奶少稗骂键拾辊嫌赶俺颁矗最邓初惜dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Procedure,1
23、.Isolation 2.Preparation 3.Lining 4.Restoration,掂游炽蜒枚钨圃腥父龄咕搽桔黔摹腿坟罢熬卵氏涕盅率插诡搂杨嫂堤淬拔dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Pulpotomy 活髓切断术 (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.,侥羹脸盲罕塞发殿萧柬患探妒灌味掉老每咏咨气芒旺琐迎
24、宠上菠术玄诸亥dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Indication 适应证,外伤性露髓 慢性牙髓炎 意外穿髓孔较大（0.5mm），破坏髓室壁、髓室顶者,根尖孔发育未完成的年轻恒牙,茵哑炮涣疙族骋旅膳鲁柏芥棺屋沪勃敛梯泵谓蘸穗形拳肠叶孵凉末尔肄伯dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Follow-up 定期复查判断疗效,术后24年内定期复查 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，即行常规根管治疗术,合肺摔芽览勾施椎舜魏膀促履雹倡豢舞霓镣佑骄玄舅袜猛遵
25、龄的控敖绊辜dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Emergency treatment 应急处理(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 irrigatio
26、n, making sure not to penetrate the 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:,馒叠量伯跑拷点吾蓖蓬蒲碌雾炙嫂临画匹财拔獭汉桶搂钳移逛躇螟管沮氖dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Summ
27、ary of Treatment of Dental Pain,Pulpal pain-irreversible pulpitis 1.Access cavity and debridement 2.Adjust,逢薄靛奢楼粗共觅紧彝攻菊臂片赌传蔑锄堤责牡粘纫碳鳞晃庭府撂忠堆篓dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Summary of Treatment of Dental Pain,Periodontal (apical) pain-acute exacerbation of chronic lesion No obvious swelling （acut
28、e apical periodontitis） 1. Debridement 2. RCT a.s.a.p. Local swelling （acute apical alveolar abscess） 1. Debridement to allow maximum drainage 2. Clean canal 3. Incise if fluctuant 4. RCT a.s.a.p. Local swelling and “cellulitis” 1. Treatment as above 2. Antibiotic therapy 3. When drainage from root
29、canal is excessive, leave canal empty but seal access. Review within 48 hours 4. Irrigate with copious amount of sodium hypochlorite irrigation 5. RCT a.s.a.p.,正称从麦郑帧窗昭曰嗽驰渴渗泥闷恕务很两孵度配吵焙乃若痒翱容尾瓣空dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Emergency Treatment,确诊后给予正确的应急处理,晋焊跃糙畴窟尺缴痈钉响奉吟彪拧遗秉慨针敬傀悉爬郭涣婚陕斡紊魁换畅dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,Emergency Treatment,手固定患牙减轻疼痛，尽量减少钻磨震动,札涩淮茅御孰爱谎拴貌酞梧佛拘滥元遭嫡态施训俞她能扼怀霄宽国允瑶搜dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,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,霸泳颁兄疗较龚状兼揭蹭肌季界反厚怕十炒仁插闻契钳帚穿莎两贵扳喀径dd牙髓病和根尖周病治疗概述P189dd牙髓病和根尖周病治疗概述P189,