z牙髓病和根尖周病

牙髓病和根尖周病 牙髓病的分类、临床表现及诊断 根尖周病的临床表现及诊断 参考书目 nEndodontics Ingle （the 5th edition） nPathway of the Pulp Stephen Cohen （the 8th edition） nDental Pulp Selzer and Bender （the 2th edition ） Clinical classification、symptoms and diagnosis of pulpal disease nClassification nDiagnostic procedures nHistologic diagnosis nClinical diagnosis Classification of pulpal disease nHistologic examination nRemoving the pulp nImpossible and unrealistic nLack of correlation between clinical signs and symptoms and the actual histologic status of the pulp Histologic diagnosis Clinical classification nBased on the patients symptoms and the results of clinical tests nDescribe the extent of pulpal disease nHelp the clinicians to selecting the correct treatment methods Clinical classification nReversible pulpitis nIrreversible pulpitis nPulp necrosis nPulp calcification nInternal resorption Reversible pulpitis (Hyperemia) nnot a disease, but a symptom npulp state: vasodilator/hyperaemia nasymptomatic nthermal stimuli (usually cold) quick, harp, hypersensitive response subsides as soon as the stimulus removed vasodilator nnot a disease, but a symptom npulp state: vasodilator/hyperaemia nasymptomatic nthermal stimuli (usually cold) quick, harp, hypersensitive response subsides as soon as the stimulus removed Reversible pulpitis Irritants n caries n periodontal scaling n root planing n microleakage n unbased restorations Reversible pulpitis Prognosis nirritant removed further appropriately treated pulp will revert to an asymptomatic uninflamed state nirritant remains symtoms pesist /more widespread irreversible pulpitis Reversible pulpitis Distinguished from irreversible pulpitis - thermal test n reversible pulpitis momentary, painful response subsides as soon as the stimulus removed n irreversible pulpitis painful, linger after the stimulus removed Reversible pulpitis Distinguished from irreversible pulpitis -complaint of spontaneous (unprovoked) pain n reversible pulpitis no! n irreversible pulpitis yes! Irreversible pulpitis nAcute pulpitis nChronic pulpitis chronic pulpitis with a closed pulp chamber chronic ulcered pulpitis hyperplastic pulpitis residual pulpitis retrograde pulpitis Acute pulpitis nThe patient is experiencing one of the most excruciating acute pains known to humanity， comparable to otic abscess, renal colic, and childbirth. nIf every dentist personally experienced the pain of advanced acute pulpalgia, he would be a more sympathetic practitioner for the experience. Acute pulpitis -This patient is in exquisite agony and sometimes becomes hysterical from the pain. -The patient often is crying and virtually unmanageable. - One patient, who had to drive 40 miles to a dentist, reported that he could stand the pain no longer, so he stopped the car, took out a pair of pliers, and pulled his own tooth. -Patients have confessed contemplating suicide to escape the pain. 牙痛不是病，痛起来要人命 Acute pulpitis Acute pulpitis (characteristics） nSpontaneous/unprovoked intermittent/continuous paroxysms nPostural change- a fitful night nTemperature change pain that lingers after the thermal stimulus is removed nNonlocalization nSpontaneous/unprovoked intermittent/continuous paroxysms nPostural change- a fitful night nTemperature change pain that lingers after the thermal stimulus is removed nNonlocalization Acute pulpitis (characteristics） Referred pain - The maxillary canine may refer to the maxillary first or second premolars and/or the first or second molars, as well as to the mandibular first or second premolars. Referred pain - Maxillary premolars may refer pain to the mandibular premolars. The reverse is also true. - Mandibular incisors, canine, and first premolar may refer pain into the mental area. Acute pulpitis (characteristics） Acute pulpitis (characteristics） Referred pain - The mandibular second premolar may refer pain into the mental and midramus area(中支) - Mandibular first or second premolars may also refer pain into maxillary molars. - Mandibular molars may refer pain forward to the mandibular premolars. Acute pulpitis （examination ） Oral/visual examination - deep caries, deep wedge-shaped defect, extensive restorations, severe abrasion, crack, deep peridontal pocket, - detection: severe pain - percussion: (-)/(+) Acute pulpitis （examination ） Thermal tests(the conclusive test) heat test (gutta-percha bar) - elicit prolonged episodes of pain linger after the thermal stimulus is removed - cold water can relieve this pain Acute pulpitis （examination ） radiograph examination - help to provide some information of the tooth: deep caries, extensive restorations pins, evidence of previous pulp capping, - a thickened periodontal membrane space at the apex，the inflammation spreads out of the pulp Acute pulpitis （examination ） Local anesthesia -Diagnosis -pain relief Local anesthesia gives blessed relief, and the dentist has, from that moment, made a friend for life. The friendship will be more lasting if the tooth is saved by endodontic therapy rather than extracted. Acute pulpitis （distinguish ） nTrigeminal pain trigger point nPapillary gingival inflammation normal teeth nAcute maxillary antrum inflammation normal teeth, headache, snuffle Chronic pulpitis Complains/“grumble” -discomfortable -mild pain -vague pain -weeks, months, or years -easy control with analgesic tablets Chronic pulpitis nchronic pulpitis with a closed pulp chamber nchronic ulcered pulpitis nhyperplastic pulpitis nresidual pulpitis nretrograde pulpitis Chronic pulpitis chronic pulpitis with a closed pulp chamber -deep caries/recurrent caries extensive restorations (near the chamber) -detection: bluntness/inaction -percussion: (+) -pulp test: no-reaction/slow-reaction -radiogralph:“thicken” periodontal membrane Chronic pulpitis chronic ulcered pulpitis -typical complain painful when compressed by food packed into the cavity -pulp chamber opened and ulcered pulp -detection: pain and bleeding -percussion: (+) Chronic pulpitis hyperplastic pulpitis -typical complain bleeding when chewing -pulp polyp(牙髓息肉) -tartar in the same side -in young people -distinguish from the other polyp 未能 Chronic pulpitis residual pulpitis -treated tooth (uncomfortable treatment) missing canal, residual pulp, -percussion: (+) -pulp test(strong): slow-reaction -radiogralph:“thicken” periodontal membrane -final decision: painful when canal detection Chronic pulpitis retrograde pulpitis -pulpitis and periodontitis -deep periodontal pocket -percussion: (+) -pulp test: difference -radiogralph：radiolucency around the root and furcation Pulp necrosis ncoronal discoloration with no true symptomes nan accident of years ago npercussion: (-) npulp test: no reaction nradiogralph: normal ndistinguish from chronic periapical periodontitis ncoronal discoloration with no true symptomes nan accident of years ago npercussion: (-) npulp test: no reaction nradiogralph: normal ndistinguish from chronic periapical periodontitis Pulp calcification nNo true symptoms nRadiograph: pulp chamber calcified locally or dispersedly nan accident of years ago/calcium hydroxide treated Internal resorption n“pink tooth” nvisual examination nradiographic examination nthermal tests and the electric pulp tester Symptoms and diagnosis of periapical disease nAcute（symptomatic） periapical peridontitis nChronic （asymptomatic ） periapical peridontitis Etiolog y nPulpal inflammation into the periapical tissue nMechanical or chemical trauma by endodontic instruments or materials nOcclusal trauma cause by hyperocclusion or bruxism Acute periapical peridontitis Periradicular pain -may be almost as excruciating as pulp pain and may often continue for a longer period of time -the severity and the rapidity of the course of the lesion -is by far the most distressing periradicular lesion Acute periapical peridontitis Periradicular pain -described as constant, gnawing, throbbing, and pounding -many patients beg to have the tooth extracted -swelling involved -painful tooth elevated slightly in its socket fear to touch the suffered tooth Acute periapical peridontitis Examination -deep caries, deep wedge-shaped defect, extensive restorations, severe abrasion, crack, deep peridontal pocket, -coronal discoloration -percussion:(+)(+)(+) Acute periapical peridontitis Examination-swelling -periradicular abscess -periosteum abscess -mucous membrane abscess Acute periapical peridontitis The drainages of the pus localized at the apex - periapicalperiosteum mucous membrane - periapicalroot canal(s) cavity - periapicalperiodontal membrane/pocket Distinguish from periodontal abscess -etiology -medical history -tooth status -pulp status -periodontal pocket -swelling place Acute periapical peridontitis Distinguish from periodontal abscess -swelling extension -degree of loose -percussion -radiograph -cause of disease Acute periapical peridontitis nalmost invariably a sequela to pulp necrosis with low-grade pathogenicity nThe pathosis is a long-standing “smoldering” without any subjective signs and symptoms usually accompanied by radi-ographically visible periradicular bone resorption nRadiographic findings are the diagnostic key Chronic periapical peridontitis nPeriradicular granuloma nPeriradicular abscess nPeriradicular cyst nPeriradicular condense osteitis Chronic periapical peridontitis Periradicular granuloma periradicular lesions 59.3% Granulomas 22% cysts 12% apical scars 6.7% other pathoses Nobuhara and del Rio Histologically -granulation inflammatory tissue with many small capillaries, fibroblasts, numerous connective tissue fibers, inflammatory infiltrate and usually a connective tissue capsule Periradicular gra