1、Treatment of Pulpal and Periapical Diseases1.Case Selection and Treatment Planning病例选择与治疗计划病例选择与治疗计划Pathways of the pulp,8th editionChapter Outline Common medical findings that may influence endodontics Dental evaluation Treatment planning1.1 Common medical findings that may influence endodontics1.1
2、.1 Pregnancy Not a contradiction to endodontics Modified treatment plan Defer elective dental treatment during the first trimester except emergency treatment Provide routine dental care during the second trimester Consult physician if necessary1.1.2 Cardiovascular diseaseMyocardial infarction 心肌梗死心肌
3、梗死(heart attack)within past 6 months Increased susceptibility to repeat infarctions and other cardiovascular complications Contraindication to any elective dental carePatients with a history of Heart murmur 心脏杂音 Mitral valve prolapse with regurgitation 二尖瓣回流 Rheumatic fever 风心病 Congenital heart defe
4、ct 先心病 Artificial heart valves 人工瓣膜 Increased susceptibility to infective(bacterial)endocarditis 细菌性心内膜炎 Potentially fatal complication Prophylactic antibiotic therapy预防性使用抗生素预防性使用抗生素1.1.3 Cancer Patients undergoing chemotherapy and/or radiation to the head and neck Impaired healing responses Consul
5、t the patients physician before initiation of treatment1.1.4 AIDS Infection control Asymptomatic patients are usually candidates for endodontic treatment Medical consultation before endodontic surgery for HIV-infected patients1.1.5 Diabetes Well controlled patients are candidates for endodontic trea
6、tment Medical consultation for patients with serious complications or before endodontic surgery Renal disease Hypertension Coronary atherosclerotic disease冠状动脉粥样硬化1.1.6 Dialysis 透透 析析 Bleeding tendency Elective endodontic treatment should be postponed1.1.7 Prosthetic implants Heart valves Vascular g
7、rafts Pacemakers 起搏器 Cerebrospinal fluid shunts Prosthetic joints人工关节 Antibiotic prophylaxis to prevent infection at the site of the prosthesis Medical consultation highly recommended1.1.8 Behavioral and psychiatric disordersConsultation before using Sedatives镇静剂 Hypnotics催眠药 Antihistamines 抗组胺药1.2
8、Dental evaluation Periodontal considerations Restorative considerations Endodontic considerations Surgical considerations1.2.1 Periodontal considerations Periodontal probing Mobility assessment Radiographic assessment Endodontic treatment should not be planned for teeth with poor periodontal prognos
9、is(e.g.mobility III)1.2.2 Restorative considerations Restorative treatment planning before starting endodontic treatment in a nonemergency situation Extensive loss of tooth structure Subosseous root caries(crown lengthening may be needed)Poor crown-root ratio Lack of ferrule effect Misaligned tooth
10、Consultation with a prosthodontist1.2.3 Endodontic considerations Anatomy of roots and canals Procedural errors Small mouth Instruments Operator skill Time To determine the level of anticipated difficulty To identify cases that should be referred1.2.4 Surgical considerations Of particular value in t
11、he diagnosis of nonodontogenic lesions Biopsy prior to definitive endodontic treatment 1.3 Treatment planningScope of endodontics Vital pulp therapy 活髓保存活髓保存 Pulpectomy or RCT 牙髓摘除术或根管治疗牙髓摘除术或根管治疗 Endodontic surgery 牙髓外科牙髓外科 Retreatment 再处理再处理 Hemisection or root amputation 牙半切或截根术牙半切或截根术 Bleaching
12、牙漂白牙漂白 Apexification or apexogenesis根尖发育成形术或根尖诱导术根尖发育成形术或根尖诱导术Treatment planning Treatment or extraction?What kind of treatment?Endodontic Periodontal Restorative Who will be the operator?Single-visit or multi-visit?Cost Prognosis 2.Preparation for treatment Infection control Universal precautions(o
13、peratory preparation)Instrument sterilization Tooth isolation 患牙隔离 Patient preparation Informed consent 知情同意 Pain control2.1 Infection Control Dental personnel are at risk of exposure to a host of infectious organisms Risk of cross-contamination in the dental environmentEffective infection control p
14、rocedures Reduce the number of micro-organisms in the working environment Protect patients and the dental team Improve the outcome of endodontic treatmentUniversal precautions American Dental Association(ADA)recommendation Each patient is considered potentially infectious The same strict infection c
15、ontrol policies applied to all patientsInfection control guidelinesCross-contamination related with handpieces Surface contamination 表面污染 Air contamination 空气污染 Suction contamination 回吸污染Routine placement of the rubber dam is considered the standard of care in USAReasons for use of rubber dam Protec
16、tion aspiration or swallowing of instruments or irrigants Soft tissue injury caused by instruments Efficiency Improve visibility(dry field and reduced mirror fogging)Minimize patient conversation Minimize the need for frequent rinsing Reduced risk of cross-contamination Legal considerationsComponent
17、s of rubber dam system Rubber dam(sheet)橡皮障橡皮障 Frame 橡皮障架橡皮障架 Retainers(clamps)橡皮障夹橡皮障夹 Punch 橡皮障打孔器橡皮障打孔器 Forceps 橡皮障钳橡皮障钳2.2 Informed consent Continuous rise in dental litigation For consent to be informed The procedure and prognosis must be described Alternatives to the recommended treatment must
18、 be presented along with their respective prognoses Foreseeable risks must be described Patients must have the opportunity to have questions answered根管治疗知情同意书根管治疗知情同意书 请阅读以下同意书，若您同意下列内容，请在治疗开始前签字。请阅读以下同意书，若您同意下列内容，请在治疗开始前签字。本人因诊断为本人因诊断为_,_,同意授权同意授权_医生进行医生进行_的的根管治疗（镍钛机动预备根管治疗（镍钛机动预备/手动预备，热牙胶充填手动预备，热牙
19、胶充填/冷侧压充填）。同时我也冷侧压充填）。同时我也同意上述医生在他同意上述医生在他(她她)认为必要认为必要 (或按治疗计划认为必要或按治疗计划认为必要)的情况下照的情况下照X X线片，线片，使用药物治疗、麻醉以及相关设备或处理措施。使用药物治疗、麻醉以及相关设备或处理措施。本人已充分理解根管治疗是保留患牙的最佳治疗方法。完善的根管治疗本人已充分理解根管治疗是保留患牙的最佳治疗方法。完善的根管治疗较其它牙髓治疗难度大、费时，需要精良的器械和技术，费用也较高。根管较其它牙髓治疗难度大、费时，需要精良的器械和技术，费用也较高。根管治疗需要去除牙内感染的牙髓组织（含血管、神经），然后用充填材料封闭治
20、疗需要去除牙内感染的牙髓组织（含血管、神经），然后用充填材料封闭根管。根管治疗成功率较高。但少数患牙因牙齿本身的情况较复杂，也可能根管。根管治疗成功率较高。但少数患牙因牙齿本身的情况较复杂，也可能需要再处理、根尖周手术甚至被拔除；在治疗过程中，可能出现器械折断于需要再处理、根尖周手术甚至被拔除；在治疗过程中，可能出现器械折断于根管内、根管壁侧穿或髓底穿以及牙体折裂。治疗之后，患牙通常需要以桩根管内、根管壁侧穿或髓底穿以及牙体折裂。治疗之后，患牙通常需要以桩核或全冠修复来保护和恢复患牙功能，否则易发生牙体折裂。核或全冠修复来保护和恢复患牙功能，否则易发生牙体折裂。根管治疗与麻醉的常见并发症包括：
21、疼痛、肿胀、牙关紧闭、感染、出根管治疗与麻醉的常见并发症包括：疼痛、肿胀、牙关紧闭、感染、出血以及唇、牙龈或舌的麻木，但麻木极少持续。血以及唇、牙龈或舌的麻木，但麻木极少持续。我已了解了根管治疗的情况我已了解了根管治疗的情况,就诊医生已向我介绍了根管治疗（镍钛机就诊医生已向我介绍了根管治疗（镍钛机动预备动预备/手动预备，热牙胶充填手动预备，热牙胶充填/冷侧压充填等）具体步骤及相应特点。我的冷侧压充填等）具体步骤及相应特点。我的疑问也已从就诊医生处得到满意的回答。疑问也已从就诊医生处得到满意的回答。本人同意医生采用本人同意医生采用_ _ _治疗方案，治疗方案，具体治疗费用约具体治疗费用约_元。元
22、。患者姓名：患者姓名：_ _ 时间：时间：_患者签名（若患者为未成年人则由监护人代签）：患者签名（若患者为未成年人则由监护人代签）：_ _ 主诊医生签名：主诊医生签名：_ _ 时间：时间：_ _ 2.3 Pain control Local anesthesia Divitalization 失活法失活法2.3.1 Local anesthesia(LA)When to anesthetize LA should be given at each appointment Three misconceptions Necrotic teeth may be instrumented withou
23、t LA(vital tissue may exists periapically)Patients sense aids the clinician to determine working length 根管工作长度 LA is unnecessary during obturation phase(obturation pressure and extrusion of sealer may produce pain)local anestheticsLidocaine 利多卡因利多卡因Articaine 阿替卡因阿替卡因碧兰麻碧兰麻(阿替卡因阿替卡因)Techniques Conven
24、tional techniques Supraperiosteal injection(local infiltration)Regional nerve block Supplemental techniques Periodontal ligament(PDL)injection Intrapulpal injection Intraseptal injection Intraosseous(IO)injection Maxillary posterior teeth Posterior superior alveolar(PSA)block for molars Buccal infil
25、tration for premolars Palatal infiltration for rubber dam retainer(optional)Maxillary anterior teeth Labial infiltration Palatal anesthsia for rubber dam retainer(optional)Mandibular teeth Inferior alveolar nerve(IAN)block for anterior and posterior teeth Incisive nerve block for premolars and anter
26、ior teeth Labial infiltration for anterior teethPeriodontal ligment(PDL)injection 27-gauge/short or 30-gauge/ultrashort needle Placed into the periodontal space between the root and the interseptal bone Bevel facing the root 0.2mL of anesthetic slowly deposited on the distal of each root of the toot
27、h Index of successful PDL injection Presence of resistance to anesthetic deposition Ischemia of the soft tissue at the site of injection Contraindications Presence of infection or inflammation in the area of needle insertion(e.g.acute apical abscess)Intrapulpal injection 27-gauge/short needle Insert
28、ed into the pulp chamber or canal Resistance met and 0.20.3mL of the solution expressed In lack of a snug fit of the needle warm gutta percha牙胶 inserted around the needle Injection under pressure after cooling2.3.2 失活法失活法 Devitalization 用化学药物封于牙髓创面上，引起牙髓血运用化学药物封于牙髓创面上，引起牙髓血运障碍而使牙髓组织坏死失去活力，以达到无障碍而使牙髓
29、组织坏死失去活力，以达到无痛操作痛操作 使牙髓失活的药物称为失活剂使牙髓失活的药物称为失活剂失活失活 法可以有效地达到无痛操作，常规用于法可以有效地达到无痛操作，常规用于干髓治疗。其他去髓治疗在麻醉效果不佳，干髓治疗。其他去髓治疗在麻醉效果不佳，或对麻醉剂过敏时才采用失活法或对麻醉剂过敏时才采用失活法常用失活剂常用失活剂 多聚甲醛多聚甲醛（三聚甲醛，简称（三聚甲醛，简称“三甲三甲”）引起牙髓血运障碍而发生坏死引起牙髓血运障碍而发生坏死 毒性弱于亚砷酸较安全毒性弱于亚砷酸较安全 作用相对缓慢作用相对缓慢 封药时间：全牙髓封药时间：全牙髓14天天 根髓根髓7-10天天常用失活剂常用失活剂 亚砷酸（
30、亚砷酸（As2O3）毒性强：细胞原生质、神经、毒性强：细胞原生质、神经、血管血管 作用迅速：牙髓血运的影响作用迅速：牙髓血运的影响 无自限性：化学性根尖周炎无自限性：化学性根尖周炎 严格控制封药时间：严格控制封药时间：24-48小时小时 禁用于根尖孔未形成的患牙禁用于根尖孔未形成的患牙操作步骤操作步骤失活法失活法 增加就诊次数增加就诊次数 牙体变色牙体变色适用于后牙适用于后牙 失活不全失活不全麻醉法麻醉法 缩短疗程缩短疗程 适用于全口牙适用于全口牙 作用迅速完全作用迅速完全3.Vital Pulp Therapy活髓保存治疗活髓保存治疗 Indirect pulp capping 间接盖髓术间
31、接盖髓术 Direct pulp capping 直接盖髓术直接盖髓术 Pulpotomy 牙髓切断术牙髓切断术“Principles and practice of endodontics”2th edition3.1 Indirect pulp capping Indications deep carious lesions No history of pulpalgia No signs of irreversible pulpitis No pulp exposure after excavation of carious dentinePulp Capping MaterialsCa
32、lcium hydroxide 氢氧化钙氢氧化钙 The most commonly-used(direct)pulp-capping material Water-based calcium hydroxide Resin-based Calcium hydroxide e.g.Dycal,TimelineZinc oxide-eugenol cement(ZnOE)Only for indirect pulp cappingBactericidal effect and hermetic marginal sealCytotoxicity-use of ZnOE as a liner in
33、 deep carious lesions is still controversialProcedures1.Remove all softened,mushy or leathery dentine2.Either ZOE or Ca(OH)2 placed on the remaining dentin to kill or suppress bacteria3.Base4.Temporary or permanent restoration3.2 Direct pulp cappingIndications:Accidental or mechanical pulp exposure(
34、normal pulp)Cavity preparation Placement of pins Trauma Mainly for immature permanent teeth with recent(24 hr)traumatic pulp exposure or mechanical exposure during cavity preparationShould mature teeth be pulp capped?Size of exposure limited to 1mmContraindicated for carious tooth with pulp involvem
35、entEnamel-dentin fracture with pulpal involvementDirect pulp capping Hemostatic reagents止血剂止血剂 Saline 盐水盐水 Hydrogen peroxide 双氧水双氧水 Diluted sodium hypochlorite 次氯酸钠次氯酸钠 Chlorhexidine 洗必泰洗必泰Pulp capping materials Calcium hydroxide Mineral trioxide aggregates(MTA)矿化三氧化聚合物矿化三氧化聚合物Procedures1.Ca(OH)2 ap
36、plied to the exposure to stimulate differentiation of new odontoblast-like cells and formation of secondary dentin2.Temporary restoration placed over Ca(OH)23.Follow-up4.Permanent restoration5.Pulpotomy or endodontic treatment for symptomatic tooth3.3 pulpotomyIndication:Immature permanent teethProc
37、edures Removal of all carious dentin and pulp tissue to the level of the radicular pulp Vital pulp stump capped with Ca(OH)2 Temporary restoration Follow-up Asymptomatic:permanent restoration Symptomatic:endodontic treatmentPotential problems with pulpotomy as a permanent treatment Impossible to det
38、ermine whether all disease tissue has been removed The remaining radicular pulp tissue may undergo mineralization Making further endodontic treatment difficult or impossible Internal resorptionConclusions The vital pulp therapies are predictable in teeth with traumatic or mechanical pulp exposure.Di
39、rect pulp capping is contraindicated for teeth with carious pulp exposure.Pulpotomy might be the choice but is considered unproven.When for financial or other reasons extraction is the only alternative,pulpotomy certainly should be considered for the benefit of the patient.4.Emergency TreatmentPretr
40、eatment emergency Irreversible pulpitis without acute apical periodontitis Irreversible pulpitis with acute apical periodontitis Pulp necrosis with acute apical periodontitisPathways of the pulp,8th editionPrinciples and practice of endodontics,2th edition4.1 Irreversible pulpitis without AAPPrincip
41、les:Complete pulp removal Total cleaning and shaping(C/S)of the root canal system 根管清理和成形 Pulpectomy is the best to achieve pain reliefPulpectomyComplete removal of the vital pulp tissue followed by cleaning,shaping and filling of the root canal(s).Indicated for tooth with pulpitis Multirooted teeth
42、 at the emergency visit Pulpotomy(removal of the coronal pulp)or patial pulpotomy(removal of the pulp from the widest canal)acceptable but less predictable in pain reliefProcedure C/S of the root canal system A dry cotton pellet placed in the pulp chamber Complete caries removal and effective tempor
43、ary coronal seal to prevent contamination Occlusal reduction 咬合调整4.2 Irreversible pulpitis with AAPCombination of pulpal and periapical symptoms Complete pulp removal and C/S Ca(OH)2 medication in canals to prevent bacterial regrowth Effective temporary coronal seal Occlusal reduction Oral analgesic
44、 medication when necessary4.3 Pulp necrosis with AAP Without swelling With localized swelling With diffuse swellingWithout swelling Thorough removal of necrotic pulp Complete C/S of the root canal Introducing a small file(#10/15)slightly beyond the apex to establish drainage from the periapical tiss
45、ues Ca(OH)2 dressing between visits to help eliminate remaining bacteria Oral analgesicsWith swelling Principle:debridement清理清理 and drainage Three ways to resolve swelling and infection Drainage through the root canal Drainage by incising a fluctuant swelling(incision and drainage,I&D)Antibiotic tre
46、atmentLocalized swellingFirstly try to establish drainage from root canals C/S of the root canal Introducing a small file(size 10/15)slightly beyond the apex to establish drainage No I&D in case of good drainage Ca(OH)2 medication Access seal If pus continues to drain through the canal and cannot be
47、 dried within a reasonable period of time,the tooth may be left open for 24 hrsIncision and drainage Indicated for localized fluctuant soft tissue swelling Principles Incise at the site of the greatest fluctuance Dissect gently and extend to the roots Keep wound clean with hot saltwater mouth rinses
48、 or CHX mouth rinseDiffuse swelling Possible to turn into a medical emergency and life-threatening condition Principles Thorough C/S of the canals Apical patency achieved whenever possible Tooth left open I&D in the absence of drainage through the canals with a rubber dam drain inserted or sutured(2
49、3 days)Referral to oral surgeonsAntibiotic therapy Indicated for patients with Diffuse swelling regardless of the establish of drainage Spreading infections or systemic signs Penicillin(1st choice)or clindamycin or erythromycin+MetronidazoleEndodontic Emergency TreatmentDiagnosis and SymptomsIrrever
50、sible pulpitisWithout AAPWith AAPPulpal necrosiswithout swellingWith localized swellingWith diffuse swellingTreatmentComplete C/SComplete C/SCa(OH)2 dressingComplete C/SCa(OH)2 dressingComplete C/SCa(OH)2 dressingI&DComplete C/SCa(OH)2 dressingI&DPostop MedNSAIDscorticosteroidsNSAIDscorticosteroidsN
