Therapy Introduction 牙髓病和根尖周病治疗概述 ( P.189)

1. Therapy Introduction牙髓病和根尖周病治疗概述(P.189)

2. Principle and Planning治疗原则和治疗计划

3. Treatment Principle治疗原则 1、Preserving Vital Pulp 保存活髓 2、Preserving Offending Tooth 保存患牙

4. 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

5. 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

6. 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

7. Absorbents 隔 湿 Cotton rolls

8. Rubber Dam橡 皮 障

9. Suction吸 唾 器 Saliva evacuator Saliva ejectors

10. Pain Control无痛技术 • Local Anesthesia 局部麻醉法 2％ Lidocaine＋Epinephrine

11. 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 • Intrapulpal anesthesia 牙髓内注射

12. 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）

13. 盖髓术 Pulp Capping • 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

14. 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

15. 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 Drugs in Pulp Capping and Pulpotomy常用盖髓剂 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

16. 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

17. 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)

18. Direct Pulp Capping直接盖髓术 Pulp capping implies placing the dressing directly onto the pulp exposure.

19. 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。

20. 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

21. 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

22. 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 a sealing restoration is then placed to seal out bacteria and their by-products.

23. 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

24. 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

25. 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）

26. 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

27. 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

28. 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

29. Local Factors 局部因素 6） Periodontally involved teeth 牙周疾患的牙齿盖髓效果差

30. Local Factors 局部因素 7） Crown and bridge 冠桥修复的基牙为禁忌症

31. Systemic Factors全身因素 • 干扰牙髓组织的修复

32. 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

33. 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

34. 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.

35. Indirect Pulp Capping间接盖髓术 （P.206）

36. 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。

37. 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无明显自发痛的慢性牙髓炎和可复性牙髓炎的鉴别

38. 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 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.

39. Procedure 1.Isolation 2.Preparation 3.Lining 4.Restoration

40. Pulpotomy 活髓切断术(P.207) Pulpotomy implies the removal of coronal pulp tissue to the level of healthy pulp. 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

41. 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

42. Follow-up定期复查判断疗效 • 术后2～4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

43. 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 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:

44. Summary of Treatment of Dental Pain • Pulpal pain-irreversible pulpitis 1.Access cavity and debridement 2.Adjust

45. Summary of Treatment of Dental Pain • Periodontal (apical) pain-acute exacerbation of chronic lesion No obvious swelling （acute 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 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.

46. Emergency Treatment • 确诊后给予正确的应急处理

47. Emergency Treatment • 手固定患牙减轻疼痛，尽量减少钻磨震动

48. 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