Transcript 的根管治疗 - shabeelpn

Treatment of
Pulpal and Periapical Diseases
1. Case Selection
and Treatment Planning
病例选择与治疗计划
Pathways of the pulp, 8th edition
Chapter Outline
• Common medical findings that may
influence endodontics
• Dental evaluation
• Treatment planning
1.1 Common medical
findings that may influence
endodontics
1.1.1 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 necessary
1.1.2 Cardiovascular disease
• Medically compromised patients
• Consult with physicians before initiation of
treatment
Myocardial infarction 心肌梗死
(heart attack) within past 6 months
• Increased susceptibility to repeat infarctions and
other cardiovascular complications
• Contraindication to any elective dental care
Patients 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 defect 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
Coronary artery bypass graft
• Antibiotic prophylaxis is not needed after
the first few months of recovery
• Consultation is advised
1.1.3 Cancer
Patients undergoing chemotherapy and/or
radiation to the head and neck
• Impaired healing responses
• Consult the patient’s physician before
initiation of treatment
1.1.4 AIDS
• Infection control
• Asymptomatic patients are usually
candidates for endodontic treatment
• Medical consultation before endodontic
surgery for HIV-infected patients
1.1.5 Diabetes
• Well controlled patients are candidates for
endodontic treatment
• 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
透析
• Bleeding tendency
• Elective endodontic treatment should be
postponed
1.1.7 Prosthetic implants
–
–
–
–
–
Heart valves
Vascular grafts
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 recommended
1.1.8 Behavioral and psychiatric disorders
Consultation before using
• Sedatives镇静剂
• Hypnotics催眠药
• Antihistamines 抗组胺药
1.2 Dental evaluation
•
•
•
•
Periodontal considerations
Restorative considerations
Endodontic considerations
Surgical considerations
1.2.1 Periodontal considerations
•
•
•
•
Periodontal probing
Mobility assessment
Radiographic assessment
Endodontic treatment should not be
planned for teeth with poor periodontal
prognosis (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
• Consultation with a prosthodontist
1.2.3 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 referred
1.2.4 Surgical considerations
• Of particular value in the diagnosis of
nonodontogenic lesions
• Biopsy prior to definitive endodontic treatment
1.3 Treatment planning
Scope of endodontics
• Vital pulp therapy 活髓保存
• Pulpectomy or RCT 牙髓摘除术或根管治疗
• Endodontic surgery 牙髓外科
• Retreatment 再处理
• Hemisection or root amputation 牙半切或截根术
• Bleaching 牙漂白
• Apexification or apexogenesis
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
(operatory preparation)
– Instrument sterilization
– Tooth isolation 患牙隔离
• Patient preparation
– Informed consent 知情同意
– Pain control
2.1 Infection Control
• Dental personnel are at risk of exposure to a
host of infectious organisms
• Risk of cross-contamination in the dental
environment
Effective infection control procedures
• Reduce the number of micro-organisms in the
working environment
• Protect patients and the dental team
• Improve the outcome of endodontic treatment
Universal precautions
• American Dental Association (ADA)
recommendation
• Each patient is considered potentially
infectious
• The same strict infection control policies
applied to all patients
Infection control guidelines
• Dental personnel vaccinated against hepatitis B
• Thorough and updated patient medical history
• Proper barrier techniques for dental personnel
– Masks, protective eyewear, disposable latex
gloves
– Hands, wrists and lower forearms washed with
soap
– Use of vacuum suction (high-volume
evacuation) for high-speed handpiece, water
spray or ultrasonics
– Use of rubber dam
Cross-contamination related with handpieces
• Surface contamination 表面污染
• Air contamination 空气污染
• Suction contamination 回吸污染
Rubber Dam
橡皮障
Routine placement of the rubber dam is
considered the standard of care in USA
Reasons for use of rubber dam
• Protection
– 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 considerations
Components of rubber dam system
•
•
•
•
•
Rubber dam (sheet) 橡皮障
Frame 橡皮障架
Retainers (clamps) 橡皮障夹
Punch 橡皮障打孔器
Forceps 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 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
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_____________, 同意授权_________医生进行________的根
管治疗（镍钛机动预备/手动预备，热牙胶充填/冷侧压充填）。同时我也同意
上述医生在他(她)认为必要 (或按治疗计划认为必要) 的情况下照X线片，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。
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。
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（镍钛机动
预备/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_____________________________ _______治疗方案，
具体治疗费用约________元。
患者姓名：
____________
时间：____________
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：____________
时间：____________
2.3 Pain control
• Local anesthesia
• Divitalization 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 without LA
(vital tissue may exists periapically)
– Patient’s 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 anesthetics
Lidocaine 利多卡因
Articaine 阿替卡因
碧兰麻
(阿替卡因)
Techniques
• Conventional 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 infiltration 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 anterior
teeth
– Labial infiltration for anterior teeth
Periodontal 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 tooth
• 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
• Inserted into the pulp chamber or canal
• Resistance met and 0.2~0.3mL 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 cooling
2.3.2 失活法
Devitalization
– 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
痛操作
– 使牙髓失活的药物称为失活剂
失活 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，
或对麻醉剂过敏时才采用失活法
常用失活剂
• 多聚甲醛
（三聚甲醛，简称“三甲”）
– 引起牙髓血运障碍而发生坏死
– 毒性弱于亚砷酸较安全
– 作用相对缓慢
– 封药时间：全牙髓14天
根髓7-10天
常用失活剂
• 亚砷酸（As2O3）
– 毒性强：细胞原生质、神经、
血管
– 作用迅速：牙髓血运的影响
– 无自限性：化学性根尖周炎
– 严格控制封药时间：24-48小时
– 禁用于根尖孔未形成的患牙
操作步骤
• 告知患者：选择失活剂、按时复诊
• 暴露牙髓：不强调彻底去腐
• 减压引流、控制出血：酚、肾上腺素棉球
• 放置失活剂：小球钻大小+丁香油棉球
• ZOE暂封窝洞
失活法
麻醉法
– 增加就诊次数
– 缩短疗程
– 牙体变色
适用于后牙
– 失活不全
– 适用于全口牙
– 作用迅速完全
3. Vital Pulp Therapy
活髓保存治疗
• Indirect pulp capping 间接盖髓术
• Direct pulp capping 直接盖髓术
• Pulpotomy 牙髓切断术
“Principles and practice of endodontics”
2th edition
3.1 Indirect pulp capping
Indications
–
–
–
–
deep carious lesions
No history of pulpalgia
No signs of irreversible pulpitis
No pulp exposure
after excavation of carious dentine
Pulp Capping Materials
Calcium hydroxide 氢氧化钙
• The most commonly-used
(direct) pulp-capping material
– Water-based calcium hydroxide
– Resin-based Calcium hydroxide
e.g. Dycal, Timeline
Zinc oxide-eugenol cement (ZnOE)
•Only for indirect pulp capping
•Bactericidal effect and hermetic marginal seal
•Cytotoxicity-use of ZnOE as a liner in deep carious
lesions is still controversial
Procedures
1. Remove all softened, mushy or leathery dentine
2. Either ZOE or Ca(OH)2 placed on the remaining dentin
to kill or suppress bacteria
3. Base
4. Temporary or permanent restoration
3.2 Direct pulp capping
Indications:
• Accidental or mechanical pulp exposure
(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 preparation
Should mature teeth be pulp capped?
•Size of exposure limited to 1mm
•Contraindicated for carious tooth with
pulp involvement
Enamel-dentin fracture
with pulpal involvement
Direct pulp capping
Hemostatic reagents
止血剂
•
•
•
•
Saline 盐水
Hydrogen peroxide 双氧水
Diluted sodium hypochlorite 次氯酸钠
Chlorhexidine 洗必泰
Pulp capping materials
• Calcium hydroxide
• Mineral trioxide aggregates (MTA)
矿化三氧化聚合物
Procedures
1. Ca(OH)2 applied to the exposure to stimulate
differentiation of new odontoblast-like cells
and formation of secondary dentin
2. Temporary restoration placed over Ca(OH)2
3. Follow-up
4. Permanent restoration
5. Pulpotomy or endodontic treatment for
symptomatic tooth
3.3 pulpotomy
Indication:
Immature permanent teeth
Procedures
• 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 treatment
Potential problems with pulpotomy
as a permanent treatment
• Impossible to determine whether all disease
tissue has been removed
• The remaining radicular pulp tissue may
undergo mineralization
– Making further endodontic treatment difficult
or impossible
• Internal resorption
Conclusions
• The vital pulp therapies are predictable in teeth with
traumatic or mechanical pulp exposure.
• Direct 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 Treatment
Pretreatment emergency
• Irreversible pulpitis without acute apical periodontitis
• Irreversible pulpitis with acute apical periodontitis
• Pulp necrosis with acute apical periodontitis
Pathways of the pulp, 8th edition
Principles and practice of endodontics, 2th edition
4.1 Irreversible pulpitis without AAP
Principles:
• 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 relief
Pulpectomy
•Complete removal of the vital
pulp tissue followed by cleaning ,
shaping and filling of the root
canal(s).
•Indicated for tooth with pulpitis
• Multirooted teeth 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 relief
Procedure
• C/S of the root canal system
• A dry cotton pellet placed in the pulp chamber
• Complete caries removal and effective
temporary coronal seal to prevent
contamination
• Occlusal reduction 咬合调整
4.2 Irreversible pulpitis with AAP
Combination 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 medication when necessary
4.3 Pulp necrosis with AAP
• Without swelling
• With localized swelling
• With diffuse swelling
Without 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
tissues
• Ca(OH)2 dressing between visits to help
eliminate remaining bacteria
• Oral analgesics
With swelling
• Principle:
debridement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 treatment
Localized swelling
Firstly 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 dried
within a reasonable period of time, the tooth may be left open
for <24 hrs
Incision 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 or CHX mouth rinse
Diffuse swelling
• Possible to turn into a medical emergency and lifethreatening 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 (2~3
days)
– Referral to oral surgeons
Antibiotic 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 + Metronidazole
Endodontic Emergency Treatment
Diagnosis and Symptoms
Treatment
Postop Med
Without AAP
Complete C/S
With AAP
Complete C/S
Ca(OH)2 dressing
NSAIDs
corticosteroids
NSAIDs
corticosteroids
Irreversible pulpitis
Pulpal necrosis
without swelling
With localized swelling
With diffuse swelling
Complete C/S
Ca(OH)2 dressing
Complete C/S
Ca(OH)2 dressing
I&D
Complete C/S
Ca(OH)2 dressing
I&D
NSAIDs
NSAIDs
NSAIDs
antibiotics