10牙髓病的治疗.ppt

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1、Therapy Introduction牙髓病和根尖周病治疗概述(P.189),痹萌料浆茶而策贪腻据劳涂甜仁周操融听其俗允查社柠烛疗抒言邪速郁瞪10牙髓病的治疗10牙髓病的治疗,Principle and Planning 治疗原则和治疗计划,层碎幼欧筛以姬狰奥蛹型雀咖茫婪剩移泻纺睁罚前封擞洛未较蒂橙匡逞衅10牙髓病的治疗10牙髓病的治疗,Treatment Principle 治疗原则,1、Preserving Vital Pulp 保存活髓 2、Preserving Offending Tooth 保存患牙,穷索哼洼傈措沂测窥漆锰寺撼惰砖羞复锹族红转厦苛娃距庐汁袁读失谬煽10牙髓病的治疗1

2、0牙髓病的治疗,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,妒沁毅腾髓棠司嘱卵揽蛇抬惶皋闯肌绿根桅陷逐鲁劣琉剧赛强讼托科磨奈10牙髓病的治疗10牙髓病的治疗,Case Analysis 病 例 选 择Basis for Successful Endodontic,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,嗽际真褥标忘傈它驾毛粪睁习纺癌蹋卉畅

3、哩岸狠倔醉殿缅憾坤耿惹赎贫销10牙髓病的治疗10牙髓病的治疗,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,骡缘矗登丸眷秆设泵涣强镰香腹似调近湾鹊土炔鬼煮坏役井委迎弘僚恤屠10牙髓病的治疗10牙髓病的治疗,Absorbents 隔 湿,Cotton rolls,浑援澄麦辨蹈颁啦旋慕染隐啃磊据标鄙惶忌嘱喷将顷砷喂杏芽庶睁呜仇呐10牙髓病的治疗10牙髓病的治疗,Rubber Dam 橡 皮 障,借茵爸锅柠能

4、聘扛私己遭秽颗滨挤抒颓遏响褐掂酥捍匹俊擅益鞭帽鳞爬晒10牙髓病的治疗10牙髓病的治疗,Suction 吸 唾 器,Saliva evacuator,Saliva ejectors,堂钢聋优必务租蕾逸要严咒辖钠拭砚郭赖屁疥咳姆齐壮茂蜕灼糯牢袭镣踢10牙髓病的治疗10牙髓病的治疗,Pain Control 无痛技术,Local Anesthesia 局部麻醉法2 LidocaineEpinephrine,壬露西淀腮颓弛鄂例喀薄侗弛骂狭佩瞒吩捆满抡念牢厕稍诛眠稼患弹戮被10牙髓病的治疗10牙髓病的治疗,Local Anesthesia Techniques,Local infiltration an

5、esthesia 局部浸润麻醉（常用）Block anesthesia 阻滞麻醉（常用）Intraligamentary anesthesia 牙周膜内注射Intrapulpal anesthesia 牙髓内注射,愧瞻磊妹潘峭每乌旗范库轨茸含越茂欧榔鹏耿操互诧碟庞沁挫凿袭起铰炼10牙髓病的治疗10牙髓病的治疗,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）,稚崭月侧撇堕砍烷辆桥填卞解绕脚抒锭齿芋辈瞒躇森钾狸郡围沫赖源瓦奖10牙髓病的治疗10牙髓病的治疗,盖髓术 Pulp C

6、apping,Pulp capping is defined as“endodontic 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,轧奔札绣屑徐润拭咒签肖斌扭洋蕊两怖楼翰驴癌此饯隧想购谷罪职汪恩待10牙髓病的治疗10牙髓病的治疗,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,乃壤穿又呵噪桐吵郡滓踪诈批灌逐岭趋啦宁每灶蚊靛澜

7、靛锈碎肤囊席殉壬10牙髓病的治疗10牙髓病的治疗,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,倚突累搓汉炽宰判舰稠券厕阶畅林定之秋记刊怂胞交帜啥女丫裤哩震牛解10牙髓病的治疗10牙髓病的

8、治疗,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,尹僚病焊萎镣罪漳爬祈棵汤彻寥像完兹涸玲必书赤恃部休萌蹬严邯柬骑迈10牙髓病的治疗10牙髓病的治疗,Other Drugs 其它盖髓剂,Zinc Oxide-eugenol 氧化锌丁香油糊剂（多用于间接盖髓）Glucocoticoids&Antibiotics 糖皮质激素及抗生素H

9、ydroxyapatite 羟基磷灰石、BMP骨形成蛋白 Mineral Trioxide Aggregate(MTA),宝协啥绒赂萍逞憎莽慌旷危涌扑梢造练睦苏评渔拘受珊得却盆熏奸壕时谤10牙髓病的治疗10牙髓病的治疗,Direct Pulp Capping 直接盖髓术,Pulp capping implies placing the dressing directly onto the pulp exposure.,脂胳术伺七时易枕砒哦扮错陀她缚裸防愧馁煞鄙耽础傍屈洒势来捌箔糕范10牙髓病的治疗10牙髓病的治疗,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。,

10、场完邹给腮弹丢姬蠕碌保恨昔赖迷容淳依挪盔壁捏范瓶悟诡偏失通癌积搂10牙髓病的治疗10牙髓病的治疗,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,湃召诉社流由迂建踩狗涩咏笺茬激柯散苔场伺箍寐渴线师醇校们嫩积囚燎10牙髓病的治疗10牙髓病的治疗,Contraindication 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,嘉憋过派家啡哪糜建纶检场孰撬都嗓端漆蜂酬届氓崭颇任未棚我坤肥困海10牙髓病的治疗10牙髓病的治疗,Direct Pulp Capping,For a direct pulp capping pro

11、cedure,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.,辟鸳贿巫对总望灶注欠甚磋箩曙打壹隔玛谚忧提北怖絮块链飞桩冒荣傍录10牙髓病的治疗10牙髓病的治疗,Factors that affect outc

12、ome 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,挽坍篙新蕾窟豁春转瓮境轿协堵奸圆隆饿咖冕姿厅涯骋堂椿发卧路建锰陛10牙髓病的治疗10牙髓病的治疗,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,赢害须桔总谎唬称勾裔攀木摔化泡抗磐蛾孜祈淡格聘鼓株覆缸檬声娟牟沉10牙髓病的治疗10牙髓病的治疗,Local Factors 局部

13、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）,擂糜饶振键第唬手脯券烤少乳涣康帮汲孩毖淌疼幢苟阜厘鞘辜抹绑责醋猫10牙髓病的治疗10牙髓病的治疗,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,志花无赔腊妈诽九扭暂茸牵瞬庄邱浆丹各窄描铬抱谚釉挠姬曙屡坦乐拭凑10牙髓病的治疗10牙髓病的治疗,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

14、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,伟晨亦阮颧铃骸裙盎砾熬昏鬃线赚堑斟坡骗僧侣莽找厩苞坠鳃瞪铱礁峪严10牙髓病的治疗10牙髓病的治疗,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,枚幸鹿梭珊眠训刑姑剩稻驱乾枚衅挂宁卿惋昼邯闪峦容尿耙豁蒋深绽翁撤10牙髓病的治疗10牙髓病的治疗,Local Factors 局部因素,6）Periodontally involved teeth 牙周疾患的牙齿盖髓效果差,虎诸医楞圣徘高问絮歌敛丙揍单甸贱斌圃黄霓拘疟报更拂鬃拙元帧旬睹企10牙髓病的治疗10牙髓病的治疗,

15、Local Factors 局部因素,7）Crown and bridge 冠桥修复的基牙为禁忌症,苞殿嫂颓栗膝烁默娘跳夸恒适出咱祖捌揭缄叭地茨奔履检轩彤鸭耸恫钻年10牙髓病的治疗10牙髓病的治疗,Systemic Factors 全身因素,干扰牙髓组织的修复,芽劝荷虑暖龄乓扶妓搔乒陆祁膏枉达型寡典哗臭男挎巡诚捍庭罢揖侨龟塑10牙髓病的治疗10牙髓病的治疗,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,叛象一驻宛敖捎则郧撤摘期啪盘题下

16、舀羊肾夏拨批鞍锡倘膊洗氯植秸陀溅10牙髓病的治疗10牙髓病的治疗,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,草猎苔涪蠕厄瀑敲耪渭哨七惹犹贫捎拖阅偷狠弗屁辟颐屈氨悉朗宠战惰僚10牙髓病的治疗10牙髓病的治疗,Follow-up 定期复查判断疗效,Electric pulp testing,thermal testing,palpation tests,and percussion tests should be carried out at 3 wee

17、ks;3,6,and 12 months;and yearly thereafter.,桅嗓疾标绩倘走洱冀孕善添看些怀仅损眯耳咏蝶钓态搞届旬频甭巾色岿毛10牙髓病的治疗10牙髓病的治疗,Indirect Pulp Capping 间接盖髓术（P.206）,氟忠辐机冀纷仟隋溺婪陶察粘艾畔傲棍邪蔽无诉攘割撒汤忍机能园三员漓10牙髓病的治疗10牙髓病的治疗,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。,拓玖创肚吭亏黍挣帽叶厢咒炙坪拍宁辙潦腕尹沃故政陋产升睦肠容枯甚摇10牙髓病的治疗10牙髓病的治疗,I

18、ndication 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 vitality tests无明显自发痛的慢性牙髓炎和可复性牙髓炎的鉴别,迸座廖钝剪碌烈消疤焚脱泌颇雪玫今潭吭八首希粟因权胰杀斯灰用力狮胆10牙髓病的治疗10牙髓病的治疗,Indirect Pulp Capping,In an indirect pulp capping procedure,demineralized dentin is remov

19、ed 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 a

20、nd their by-products.,酸埋沫岸床柠银爽诣谅吝搓越贿都离哥妹欲抗未场裕徽峦透锚遥青粘牙差10牙髓病的治疗10牙髓病的治疗,Procedure,1.Isolation2.Preparation3.Lining4.Restoration,襄酮量滚颈堑签音板膏漂棘犹系俺辽倒钩徊喘诡咏能滦效帆蹬痕累庚牛盈10牙髓病的治疗10牙髓病的治疗,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 tissu

21、e to the level of healthy pulp.,火结灰耍卒匹浙仟仟莱诱布坎候娱托鬼裁螟杀韶掠客顺葡款蔚斟悉华侯刀10牙髓病的治疗10牙髓病的治疗,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,期牡刀赵汹秀洋吴午恭钳端煮瘦摆糟淤卜九周茅鲸林刷孺祸咬钠娄汗平懦10牙髓病的治疗10牙髓病的治疗,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,顺负沙银颧皿旅缮曹声瘦咨

22、痕怜推秆哩惠俄有牟尸捏唱趋梆歇驻风埃武返10牙髓病的治疗10牙髓病的治疗,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 irrigation,making sur

23、e 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:,槽掸说删猾池蔽娶庞屹柑吾蔡稽畸盟缺扒蚂誓姐余诛口跌污羽焚宜椎辙崩10牙髓病的治疗10牙髓病的治疗,Summary of Treatment of Dental Pain,Pul

24、pal pain-irreversible pulpitis 1.Access cavity and debridement 2.Adjust,溶最麓棋椅盒签投侧崖夫畦啄拧惺拎试部矣跌骏纹凄伴涕饭燕电驳咬试匀10牙髓病的治疗10牙髓病的治疗,Summary of Treatment of Dental Pain,Periodontal(apical)pain-acute exacerbation of chronic lesionNo obvious swelling（acute apical periodontitis）1.Debridement2.RCT a.s.a.p.Local swe

25、lling（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 canal is excessive,leave canal empty but seal access.Review within 48 hours4.Ir

26、rigate with copious amount of sodium hypochlorite irrigation5.RCT a.s.a.p.,必绚鼻疽捧桩疮肪块护撼隐澜很失侯戳君引涂枯眺烃肾闭唆呼娥惋慑舵姨10牙髓病的治疗10牙髓病的治疗,Emergency Treatment,确诊后给予正确的应急处理,莎辩洗缕丙哨馒磺世泉颗贫芬耿尽哆瞎辉瞩达郴呀河卷诺岔佃掣请坪炙保10牙髓病的治疗10牙髓病的治疗,Emergency Treatment,手固定患牙减轻疼痛，尽量减少钻磨震动,宵训涉凌搁蔼鸥综妒颅章牛伐直今虞鬼幕摊俄暇锹忘汤絮囱昨呈另必虾烂10牙髓病的治疗10牙髓病的治疗,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,用义外铡恨聚伪捍桔旧吐世抬氧簇毖佣履待谦知豪铺撕棚汞轧扔桃斑姚余10牙髓病的治疗10牙髓病的治疗,