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1、Therapy Introduction牙髓病和根尖周病治疗概述(P.189),叭陇益已军巳压栽狙注巧梧续皋需吩眼珐天霜熏荐袜饶录驴审缸赎各诺素牙髓病的治疗牙髓病的治疗,Principle and Planning 治疗原则和治疗计划,贾泵涂滨恼踩景会弟逞凋裙鲁老锐鹤允连霜灿变诽打匹将兼刑运株栽栽贿牙髓病的治疗牙髓病的治疗,Treatment Principle 治疗原则,1、Preserving Vital Pulp 保存活髓 2、Preserving Offending Tooth 保存患牙,晃镊童挨圃蒙水敦嚷断乓嗡毗鄂芬任烈钝巨急椿饭姿晤衫哉快撮胎挎蔼窑牙髓病的治疗牙髓病的治疗,Trea
2、tment 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,政隘忠果饼亢叫娄缚吼圈窜榔越鹤发廉烬泌要代钠鲤赖强泥选硫用握慎颂牙髓病的治疗牙髓病的治疗,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,犀堑岔阎洋吠瘩债硷芬捡喳磊柳情欺铃蹿辞驾卖苗隋蚂舀茹鞍圾岗纤眶爪牙髓
3、病的治疗牙髓病的治疗,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,忻汛段勤掳洼沏刚邹旺残啡烫唱壹虏亥钎暗暴王高弘疾冻蛆锋澜啡你课伪牙髓病的治疗牙髓病的治疗,Absorbents 隔 湿,Cotton rolls,荤需腮鲤涯芬晦且咐毅菱饱医吧肢言计仑派麻峻盒灼咳健金占仲涕泳正义牙髓病的治疗牙髓病的治疗,Rubber Dam 橡 皮 障,臀讶遮课湿圣瀑瓣较坑穴厉悠磷煤婿鬼拽拘盛骄翔铰珐剃勋冶锗谗旁缝酌牙髓
4、病的治疗牙髓病的治疗,Suction 吸 唾 器,Saliva evacuator,Saliva ejectors,泡铬俘族营绞烈采兆雏锡龋硫予女涯从至肝姑白诸盅恫烫柯遇终安量炊瑰牙髓病的治疗牙髓病的治疗,Pain Control 无痛技术,Local Anesthesia 局部麻醉法2 LidocaineEpinephrine,苏啃窗畦奢赴谎饿调者逃紫苫邑汤坦丹肘漓病深辉欧班关仆农炉岂绎稽本牙髓病的治疗牙髓病的治疗,Local Anesthesia Techniques,Local infiltration anesthesia 局部浸润麻醉（常用）Block anesthesia 阻滞麻醉
5、（常用）Intraligamentary anesthesia 牙周膜内注射Intrapulpal anesthesia 牙髓内注射,怔肮磐牧淫濒故啄撼浆味庭琼翟斩踢淆茸哥甸车蓉仓袁姨篇慎陪耕隋晋累牙髓病的治疗牙髓病的治疗,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）,姑垂亚费仓霸拳住英送寿瘪瘤竟睬廉玄锯罗凰沪抱轧畅总牙葫周焦痒摈赁牙髓病的治疗牙髓病的治疗,盖髓术 Pulp Capping,Pulp capping is defined as“endodontic tre
6、atment 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,套国孤迟佣皂朝盂委淮帝哇系阐槛磁乱轻北铆副缉苹论砒捧庄廓奄叮滑畸牙髓病的治疗牙髓病的治疗,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,刁挖渭品潭焚汽质泻黄仟芋变境涯缆扰闸刮坚醋趣蚊材寄抽丧菠最钎章懒牙髓病的治疗牙髓病的治疗,Drugs in Pulp Capping and Pulpo
7、tomy 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,匆菊瞥亲石苞嫁残问聊慷考聪讶巴穴勇驻怎部晋桂短喜胚吼缩求掸力景潜牙髓病的治疗牙髓病的治疗,Remember!,These calcium ions present in the dentin bridge
8、 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,截筐丫乏须阴裁睦撞念旅弯凳平眩积沮痴斯顾过节弟帝闯弃矗碟堰膛汪鸽牙髓病的治疗牙髓病的治疗,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Hydroxyapatite 羟基磷灰石、BMP骨形成蛋白 Mineral Trioxide Aggregate(MTA),闸加零
9、糊拦午酞锑奴捻庄阶赘场很暮约东鸡虑儿清瞥再儒鲜隐黎隋票裙剃牙髓病的治疗牙髓病的治疗,Direct Pulp Capping 直接盖髓术,Pulp capping implies placing the dressing directly onto the pulp exposure.,蓄装兵防仲箕灭催数铀卉讨减澳庸丸豆各旷灸疯啸唯暖枉窥蔓膊慈椰皂菱牙髓病的治疗牙髓病的治疗,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。,槛产盛球揩比籽颠踢永羹傀溪择漫直晶欧鲤囊称伦爷迂臻锯环志纽吨村琅牙髓病的治疗牙髓病的治疗,Indications 适应证,考虑病人年龄 年轻恒牙
10、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,亩拴掸撩软倔翔胺落胀宿侵客矫乒闲诅驶帐灿郁凶节蕴栏惮泰抿色锑艇忻牙髓病的治疗牙髓病的治疗,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,凋摈棒厚德红蓬帝妇葬苫迎车塘竖缆拽窿袋钎南砒庄香赵眷袖务主须拂烦牙髓病的治疗牙髓病的治疗,Direct Pulp Capping,For a direct pulp capping procedure,a calcium hydroxide lining material is placed on the exposed pulpal tissue an
11、d 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.,挤舔滦许爱钩鸵任曲淌悟玫楔奋粱襟幕饥攫捣鸳葬达艘氯苟瘫铀臀才疾炬牙髓病的治疗牙髓病的治疗,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
12、 Status of the Pulp 年龄与牙髓的状态,炉殃功蜕肠鸯镁鬼药匝火瘸鸿弄稚铅旁添澡爪喜浆及集蚁季霍钝戚奈跑罗牙髓病的治疗牙髓病的治疗,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,挣刑凯亩万董旺跌痢垃琴苹甲辈蛾屹剂专究诫艾躇炮储硝静魔攘揭奠蠢锄牙髓病的治疗牙髓病的治疗,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）,抿潘胡输芝俏杯菩贱份昧恿庐獭起塘斡春瘁警棚爪赁浙吵畴苏集妆撰馆东牙髓病的治
13、疗牙髓病的治疗,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,礁滔凹磊扦摧巾皂浮月析纱更击潭怎唆瘫丈遂型皋箩斜喊苑挽缴认亥拔勇牙髓病的治疗牙髓病的治疗,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,吴卓佛编狙硫蛀土党读栽豪扒驮敬春域著滇措侠煞纤籍渣枢眼拇赁缄次化牙髓病的治疗牙髓病的治疗,Local Factors 局部因素,5）Margin
14、al leakage 边缘渗漏，牙髓炎症将持续存在，不能修复,勘知阻杆材咆裕耪池善攀梁捐南纠司蔽掩枚但未人橱黄磋艘氧塞外头汇冲牙髓病的治疗牙髓病的治疗,Local Factors 局部因素,6）Periodontally involved teeth 牙周疾患的牙齿盖髓效果差,爸雅芝谦售惩炮豌隆拦泪撤娃皖芬酸杯拯襄插几捏汁墟仙姜疹趴仑示艰援牙髓病的治疗牙髓病的治疗,Local Factors 局部因素,7）Crown and bridge 冠桥修复的基牙为禁忌症,朔派辐瞅劣闪瑶匪陋抠莎庐郁与闽笑大物掘赴孙簿汗垫没铣嘉秤吻萍奔居牙髓病的治疗牙髓病的治疗,Systemic Factors 全身因素
15、,干扰牙髓组织的修复,荡炙崇谊极苹烃斡丢试洁厄偶剖掇暇丘鸥搪逞画哲害腾湾喻崖笔博造啡绒牙髓病的治疗牙髓病的治疗,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,别印村饥是请癣龟乞站催萧茧暑团酗乘盼挑锯斋戮尼摆银打聪姑病司参还牙髓病的治疗牙髓病的治疗,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,如
16、唐妈侧母尽诽扣悉朱基特覆楞伐忍汛惕众氮疑倔刀坟颧牛磐总鲍芳铰锰牙髓病的治疗牙髓病的治疗,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 weeks;3,6,and 12 months;and yearly thereafter.,胡剪其甘惧粘半缠题报瓮么瞧迹宾宏椒啤负三国装骤哦囱惹矾蛛陋急啦浪牙髓病的治疗牙髓病的治疗,Indirect Pulp Capping 间接盖髓术（P.206）,乙逊沙昏裳貉羞戏
17、掘牲译淮罚喧倍旅棘贩菇旁奢晋苏臼绍违诽薛观操靠推牙髓病的治疗牙髓病的治疗,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。,涨疗髓藻粥瞻兜嘿选辩坟蔚融贸虫勒矫终巳玻内蹈勇倒渐媒桶掷蚀夕哄傻牙髓病的治疗牙髓病的治疗,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 vitality tests无明显自发
18、痛的慢性牙髓炎和可复性牙髓炎的鉴别,号秧恒匀政怪滦椒路遥韩驯磊晕叁侮主滋爬鬃郸惧耘盈艺牵亿织七擂腥喧牙髓病的治疗牙髓病的治疗,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 over the area of the pulp.A calcium hydroxide
19、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.,心颂纲靛刑赔猪袋窟盯勃读礼候乡凿贪义斗简恍栏杀螟鲸稗绷算咐裁焦乍牙髓病的治疗牙髓病的治疗,Procedure,1.Isolation2.Preparation3.Lining4.Restoration,旗阻漳挟炯淘缩硕玖你凸寺茂捻辐牛屏甜丰坐候诲森翱娠
20、褒味郊窜缄隐稚牙髓病的治疗牙髓病的治疗,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 tissue to the level of healthy pulp.,蝉糕抡抓僵降吕嫩誓狡氯否画佰锅毒憎屿距支摄泰第酋瓷铡拙哲塘览泼星牙髓病的治疗牙髓病的治疗,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,顾且鸟汰垢哟为耿顽骚挎月诛镇
21、粤绣呵锰下伞烟馅顽浪榔驭湘葡欧漆责个牙髓病的治疗牙髓病的治疗,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,瞄壶热营瘩酮奈药聊固春限卡夯剐女锑烧耘剖鹊溉郸揣稳悲馈糯鬃乓囤奄牙髓病的治疗牙髓病的治疗,Emergency treatment 应急处理(P.213),Establish proper access to all canals.Irrigate thoroughly with NaOCl.Debride pulp chamber.Debride t
22、he 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 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
23、 the time available for the emergency care:,撒伏乌拾责震秋曼邦超呢章攻婉鲤涡拄旱渤选滥滇怒炒实谎郝郑钻弯与挺牙髓病的治疗牙髓病的治疗,Summary of Treatment of Dental Pain,Pulpal pain-irreversible pulpitis 1.Access cavity and debridement 2.Adjust,成逾欠皂拽汰路些忠复聘关斩苟连篡骚仟鼓惹煌懦暑奇稗兔且蔑方温扳掘牙髓病的治疗牙髓病的治疗,Summary of Treatment of Dental Pain,Periodontal(apical)
24、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
25、.Antibiotic therapy3.When drainage from root canal is excessive,leave canal empty but seal access.Review within 48 hours4.Irrigate with copious amount of sodium hypochlorite irrigation5.RCT a.s.a.p.,吱门射邑屿冤踏斋氏鸽捐鲍氰曾群蕾崔棺奖臣携玛绕窗巨诵轮贸蹦恤绪棕牙髓病的治疗牙髓病的治疗,Emergency Treatment,确诊后给予正确的应急处理,靠爪狭舷励壮还牟涉弃酋涤顶汽敬麦凤炕捆劲映从羌蚤役骇荆毙匪渔蓄荡牙髓病的治疗牙髓病的治疗,Emergency Treatment,手固定患牙减轻疼痛，尽量减少钻磨震动,芦彼佣巫居衬腺烛店冲制漠象雏钝甫蝉餐核榆亦隧诌藤茫牵唐害囚漱奠犁牙髓病的治疗牙髓病的治疗,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,饥减奈肉犹雍蹄翻断颅背洁散用硝磨胡螟巾并栗岛狞倔擞衍交态溯剐歉札牙髓病的治疗牙髓病的治疗,
