10牙髓病的治疗

1、(p.189) 1、preserving vital pulp 保存活髓 2、preserving offending tooth 保存患牙 nemergency endodontic treatment 缓解疼痛，控制急性症状nexamination & routine treatment 全面检查，常规治疗nmedical history 患者状态 适用于任何年龄，无绝对的全身禁忌证ndental history 患牙状态 尽可能保存患牙感染的控制无菌技术）nisolating the operative field 术区隔离nsterilizing the instrument

2、手机灭菌、器械消毒和灭菌cotton rolls saliva evacuatorsaliva ejectors 无痛技术nlocal anesthesia2 lidocaineepinephrinenlocal infiltration anesthesia nblock anesthesianintraligamentary anesthesianintrapulpal anesthesia(p.203)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）pulp capping is defined as “endodontic treat

3、ment designed to maintain the vitality of the endodontium”.n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 pulp cappingndirect pulp capping（直接盖髓术）覆盖已暴露的牙髓nindirect pulp capping （间接盖髓术）覆盖接近牙髓的牙本质 ncalcium hydroxide (highly alkaline强碱性) 最具疗效的盖髓剂之一antibacterial activity中和炎症所产生的酸中和炎症所产生的酸性产物性产物activate akp, promote dentin

4、 formation激活碱性磷酸酶，促进修复性牙本质形成激活碱性磷酸酶，促进修复性牙本质形成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其它盖髓剂nzinc oxide-eugenol 氧化锌丁香油糊剂（多用于间接盖髓）nglucocoticoids & antibiotics 糖皮质激素及抗生素nhydroxyapat

5、ite 羟基磷灰石、bmp骨形成蛋白 mineral trioxide aggregate (mta)直接盖髓术pulp capping implies placing the dressing directly onto the pulp exposure.原原 理理 用盖髓剂用盖髓剂覆盖在露髓创面上，消除覆盖在露髓创面上，消除炎症和感染，保护牙髓组织，使其恢炎症和感染，保护牙髓组织，使其恢复健康。复健康。 适应证1. 考虑病人年龄 年轻恒牙根尖孔尚未形成2. 考虑病变程度 恒牙牙髓有无感染、牙髓病变早期阶段for a direct pulp capping procedure, a cal

6、cium 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.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局部因素2）location of the exposure 露

7、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）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的范围内局部因素5） marginal leakage 边缘渗漏，牙髓炎症将持续存在，不能修复局部因素6） periodontally involved teeth 牙周疾患的牙齿盖髓效果差局部因素7） crown and bridge 冠桥修复的基牙为禁忌症 全身

8、因素n干扰牙髓组织的修复 牙髓组织的转归分为成功和失败两个方面n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）n牙髓组织慢性炎症，出现疼痛症状；牙髓钙化或内吸收失败nreported prognosis is in the range of 80%定期复查判断疗效nelectric pulp testing, thermal testing, palpation tests, and percussion tests should be carried out at 3 weeks;3,6, and 12 months; and yearly thereafter.间接盖髓术 （p

9、.206）原原 理理 窝洞中遗留的少量细菌被盖髓剂覆盖，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及细菌产酸所需的底物被隔绝而大幅度下降，降，ca(oh)2可维持局部的碱性环境，有可维持局部的碱性环境，有利于修复性牙本质的形成。利于修复性牙本质的形成。ndeep carious lesionhas no history of spontaneous pain and respond normally to vitality testsin an indirect pulp capping procedure, demineralized dentin is remo

10、ved 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 bacter

11、ia and their by-products. 1.isolation2.preparation3.lining4.restorationpulpotomy活髓切断术活髓切断术 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.定期复查判断疗效n术后24年内定期复查n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

12、常规根管治疗术 1.establish proper access to all canals.2.irrigate thoroughly with naocl.3.debride pulp chamber.4.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 ca

13、nal.5.temporarily seal the access opening.6.use analgesics as necessary.this plan of action may be undertaken depending on the time available for the emergency care:npulpal pain-irreversible pulpitis 1.access cavity and debridement 2.adjust nperiodontal (apical) pain-acute exacerbation of chronic lesion1. debridement2. rct a.s.a.p.1. debridement to allow maximum drainage2. clean canal 3. incise if fluctuant 4. rct a.s.a.p.1. treatment as above2. antibiotic therapy3. when drainage from ro