pathway10讲课益锐齿科材料M3新型机用镍钛锉读书笔记用于商业用途

PathwayofthePulp10thEdition第八器械材料和设大牙髓血管的评去除根管物的装置髓腔的材料洗必MTAD乙二胺四乙IodinePotassium固体材机用系临时修复激光掺钕钇铝榴石（单晶陶瓷）激

CHAPTERDIAGNOSTICMATERIALSANDAssessmentofPulpSensibilityAssessmentofPulpVascularityAssessmentofCracksandFracturesAssessmentofImagesENDODONTICINSTRUMENTSHandInstrumentsforCleaningandShatheRootCThroughaRootCDevicesforMeasuringRootCLengthInstrumentsforRootCObturationDevicesforRemovingRootCMATERIALSFORDISINFECTINGTHEPULPSodiumHypochloriteMTADandTetracleanIodinePotassiumIodideChoosingtheIdealIrrigantIntracMedicationTechniquesandDeviceROOT FILLINGSolidMaterialsDELIVERYSYSTEMSFORROOT在在过去的几十年里，根管治疗世界发生了很大的变化，比如材料，技术，设备，器械设计，以及用于生化：根管系统必须被和预备：去除有机残余物质，预备全OBTURATIONOBTURATIONInjectionTechniquesRotaryTechniquesTEMPORARYRESTORATIONSGarnetLasersErbium-DopedYttriumAluminumGarnetDiodeScandiumGalliumGarnetLasers器TheThepastdecadeshaveseenmanychangesinthepracticeofendodontics,suchasinmaterials,techniques,equipment,instrumentdesign,andthetypesofmetalsusedtomanufactureendodonticinstruments.However,thegoalsofnon-surgicalendodontictherapyhasnotchanged:“Rootcsystemsmustbecleanedandshaped:cleanedoftheirorganicremnantsandshapedtoreceiveathree-dimensionalhermetic(fluid-tightseal)fillingoftheentirerootcspace.DIAGNOSTICDIAGNOSTICMATERIALSANDAssessmentofPulpOneofthegreatestdiagnosticchallengesinclinicalpracticeistheaccurateassessmentofpulpstatus.Avarietyofpulptestingapproachesexist,andtheremaybeconfusionastotheirvalidityorappropriatenessindifferentclinical牙髓敏感性评牙体牙髓医生临最大的诊断困难就是牙髓的判断。目前有好几种牙髓测试方案是总是有适。在做测试诊断材料和设的最古老的方案，但是不能把对牙髓反应的评估和测试搞混，后者需要进行额外的牙髓循估。测系统内对于Aδ神经纤维造成了流神经反应。实验的方式“冰铅笔”。也可以将负41度成一个冰晶体放到牙上（见图8-1）。−50°C的氟利昂（DDM）是压缩制冷剂喷雾，也可以喷到棉

Whentestsareevaluated,therearesometermsthatmayleadtomoredefinitiveand fiableendodonticdiagnoses.Thesetermsaresensitivity,theabilityofatesttoidentifyteethwithdisease;specificity,theabilityofatesttoidentifyteethwithoutdisease;andpredictivevalue,theabilityofatestto lwhatthediagnosisactuallyis.Pulpstimulationwithcoldorheatistheoldestmethodofevaluatingthepulp’shealthanditsabilitytorespondtoexternalstimulation,butevaluationofpulpalresponsemustnotbeconfusedwithvitalitytesting,whichrequiresassessmentofpulpalcirculation.ColdColdthermaltestingcausescontractionofthedentinalfluidwithinthedentinaltubules,resultinginarapidoutwardflowoffluidwithinthepatenttubules.Thisrapidmovementofdentinalfluidresultsin sactingontheAδnervefiberswithinthepulp-dentincomplex,leadingtoasharpsensationlastingforthedurationofthethermaltest.Avarietyofcoldtestsmaybeemployed;themajordifferencebetweenthemisthedegreeofcoldappliedtothetooth.Asimplemeansofapplyingacoldstimulustoatoothistowrapasliveroficeinwetgauzeand ceitagainstthebuccalsurface,comparingthereactionbetweenthetesttoothandacontroltooth.Pencilsoficecanbemadebyfillinga sticstrawwithwaterand zingitinanuprightpositionina zer.Ethylchloride(−41°C)maybesprayedontoacottonpledget,resultingintheformationoficecrystals(fig.C)maybesprayedontoacottonpledget,resultingintheformationoficecrystals(fig.8-1)priortoapplicationtothetooth.dichlorodifluoromethane(ddM)(−50°C)isacompressedrefrigerantspraythatcanalsobesprayedontoacottonpledgetforcoldtesting(fig.8-2).Morerecently,ozone-friendlynon-chlorofluorocarbonsprayshavebeenintroducedincertain上制作冰晶体（见图8-2）FIG.8-1ethylchloridesprayedontoacottonpledget,resultingintheformationoficecrystals.(CourtesyDr.R.Portigliatti.)晶体。（DrDr.R.Portigliatti提供）FIG.8-2Hygenicendo-ice.(CourtesyColténe/Whaledent,CuyahogaFalls,OH.)图8-2的根管冰，俄亥俄州 固体二氧化碳（CO2），也称干冰etal医生的实验报告 ，干冰在接触牙齿5分钟之后，牙髓依旧可有损伤。但是另一方面，仅短短5秒，干冰棒就会对全瓷修复的瓷表 实验中，用冷媒喷雾 开，再用海绵沾冰水淋到 反应或者到15秒。冰水

Anothereffectivecoldstimulusisfrozencarbondioxide(CO2),alsoknownasdryiceorcarbondioxidesnow(−78.5°C).Fortestingpurposes,asolidstickofCO2ispreparedbydeliveringCO2intoacustom- sticcylinder,andthestickisappliedtothebuccalsurfaceofthetooth.Thismethodisparticularlyeffectivewhentryingtoassessteeththathavebeenrestoredwithfull-coveragemetalrestorations.Rickoffetal.reportedthatCO2snowappliedtoatoothfor5minutesdidnotjeopardizethehealthofthepulp,nordoesitdamagethesurfaceoftheenamel.Ontheotherhand,CO2maycausepittingofthesurfaceofporcelainrestorationswhenappliedforaslittleas5seconds.Whentestingwithacoldstimulus,theadvantageofrefrigerantspraysandfrozencarbondioxideisthatthecoldstimulusdoesnotgointoaliquidphasebutratheragasphase.Thisallowstestingtobespecifictoonetoothatatime,withoutcoldwaterfrommeltedicestimulatingadjacentteeth.ice-coldwaterisanotherusefulandinexpensivetest.Thetoothbeingtestedshouldbeisolatedwitharubberdamandthenbathedwithwaterfromasyringe.Coldtestsshouldbeapplieduntilthepatientdefini yrespondsorthestimulushasbeenappliedfora umof15Oneofthesignificantbenefitsofice-watertestingisthatitcanbeusedonanytoothregardlessofthetypeofrestorationthatmaybepresent.Overall,coldtestsappeartobemorereliablethanheattests,andthereisageneralconsensusthatthecolderthestimulus,themoreeffectivetheassessmentthestimulus,themoreeffectivetheassessmentoftoothinnervationstatus.热敏实 度可达摄氏150度：牙胶在65度200摄氏度。因为空间的限制，热Aδ神经纤维的双向刺激，然后会进一步刺激到牙髓C纤维。对牙髓C纤维的刺激可以导致持续的牙 过5秒 器喷射是最常见的方法。通过一敏测试，不会伤到牙髓组织。SystemB（盛邦公司生

HeatWarmthermaltestingisnotemployedasoftenascoldtestingbecausemostpatientsaremoresensitivetocoldstimuli,andwarmthermaltestshavebeentraditionallymoredifficulttoperform.Heattestingcanbeundertakenusingastickofheatedgutta-perchaorhotwater.Agutta-perchastick,preferablybase- tegutta-percha,isheatedwithanakedflameoranelectricheateruntil essoftandglistens.ItisthenappliedtotheVaseline-coatedsurfaceofthetesttooth.itispurportedthatatoothsurfacetemperatureashighas150°Ccanbeachievedwiththistechnique:gutta-perchasoftensat65°Candmaybeheatedindeliverydevicesupto200°C.Thistestmaybedifficulttouseonposteriorteethbecauseoflimitedaccess.Afurtherdisadvantageisthatexcessiveheatingmayresultinpulpdamage.ProlongedheatapplicationwillresultinbiphasicstimulationofAδfibersinitially,followedbythepulpalCfibers.ActivationofCfibersmayresultinalingeringpain,thereforeheattestsshouldbeappliedfornomorethan5seconds.However,inadequateheatingofthegutta-perchastickcouldresultinthestimulusbeingtooweaktoelicitaresponsefromthepulp.Theuseofhotwater,administeredthroughanirrigatingsyringeunderrubberdamisolation,hasalsobeendescribedasameansofthermaltesting.Frictionalheatmay度。在牙齿表面润滑之后，把一个测试尖绑到SystemB的手柄上，温度设置150度，在将这个预热尖放到牙齿表面，测试的反死髓牙齿热刺激下会疼痛，冷刺激断死髓牙的法。

begeneratedbyusingarubbercupintendedforprophylaxis(withoutpaste)againstthebuccalaspectofatooth.Thenormaluseofthermaltestsonteethhasbeenshownnottobeharmfultohealthypulptissue.TheSystemB(Sybronendo,Orange,CA)allowsdentiststosetspecifictemperaturesforwarmthermaltesting.Afterthesurfaceofthetoothhasbeenlubricated,atesttipcanbeattachedtothehandleoftheSystemBandthetemperaturesetat150°f.Thepreheatedtipis cedonthesurfaceofthetooth,andthepatient’sresponseisevaluated.Oneoftheproblemsoftestingwithheatisthatoftenanon-vitaltoothincreasesinpainsecondarytoheatstimuli.Intheclinicalsituationwherebyapatientreportspaintoheatandreliefwithcoldstimuli,theapplicationofcoldtoindividuallyselectedteethmayeliminatethepatient’stoothpain.Therefore,inthesesituations,theapplicationofcoldwithreliefofpaincanbediagnosticforanonvitalpulp.ElectricElectricPulpTheobjectiveoftheelectricpulptest(ePT)istostimulateintactAδnervesinthepulpal-dentincomplexbyapplyinganelectriccurrenttothetoothsurface.Apositiveresultstemsfromanionicshiftinthedentinalfluidwithinthetubules,causinglocaldepolarizationandsubsequentgenerationofanactionpotentialfromintactAδnerves.Theelectricpulptesterisabattery-operatedinstrumentconnectedtoaprobethatisappliedtothetoothunderinvestigation.Itfunctionsbyproducinga复合体中的完好的Aδ神经。阳性反Aδ神经上产生电位差。电 测测试（ePT）电电逐渐地按挡数增强。当感到热读得电流强度。读数不能量 析。如图8.3.

pulsatingelectricalstimulus,theinitialintensityofwhichshouldbesetataverylowvaluetopreventexcessivestimulation fort.Theintensityoftheelectricstimulusisthenincreasedsteadilyatapreselectedrate,andanoteismadeofthereadoutonthedigitaldis ywhenthepatientacknowledgesawarmortinglingsensation.Thereadoutisnota measurementofpulphealth;itsimplyprovidesevidencethattheAδfibersaresufficientlyhealthytofunction.Bipolarandmonopolararethetwostimulatingmodesavailable.Thebipolarmodeispresumablymoreaccuratebecausethecurrentisconfinedtothecoronalpulp,butmostePTsarestillmonopolar.TherequirementsofanePTareanadequatestimulus,anappropriateapplicationmethod,andcarefulinterpretationofresults(fig.8-3).FIG.8-3electronicpulptester.(CourtesySybronEndo,Orange,CA.)图8-3盛邦公司的电子牙髓测 究发现，如果电介质不同， 最佳位置，有不同的观点。几条神域的会有一个相对快速和响的切面边缘，这个位置是髓腔中神常，切牙最低，前磨牙还是变高，磨牙最高。最近的研究表明，测试

ToothisolationduringePTisessential.Dryingtheenamel, cementofan sticstrip,anduseofarubberdamcanpreventthespreadofelectricalimpulsestoadjacentteethorgingivaltissue.Electriccurrentcanalsobetransferredbetweenadjacentteeththroughcontactingmetallicrestorations.Aconductingmediumshouldalsobeusedtoensurethat umcurrentpassesfromtheelectrodetothetoothsurface.Alaboratorystudyconcludedthattheinterfacemediummadenoappreciabledifferencetoeitherthevoltageortheelectriccurrenttransmitted.However,amorerecentstudydiddemonstratethatdifferentmediainfluencetheresponsesgainedfromelectrictesting.Thereareseveralconsiderationsregarding cementofthetesterelectrode.Theresponsethresholdisreachedwhenanadequatenumberofnerveterminalsareactivatedtoattainwhatistermedasummationeffect.Anareaofhighneuraldensityshouldhavearelativelyfastandstrongresponseandrequirestheleastelectriccurrent.Therefore,themostdesirableareaofassessmentinincisorteethisattheincisalThetestershouldbeappliedonthetoothsurfaceadjacenttoapulphorn,theareaofhighestnervedensitywithinthepulp.Thispositionequatestotheincisalthirdregionofanteriorteethandthemid-thirdregionofposteriorteeth.Thethresholdforresponsemaybeinfluencedbythethicknessoftheenamelanddentinoverlyingthepulp.Thus,theresponsethresholdforhealthyteethmaybelowestinincisors,slightlygreaterinpremolars,andoverlyingthepulp.Thus,theresponsethresholdforhealthyteethmaybelowestinincisors,slightlygreaterinpremolars,andgreatestinmolarteeth.Arecentstudyhasrevealedthattheoptimumsitefortesterelectrode cementonmolarsisonthetipofthemesiobuccalcusp.牙髓血管的评牙髓测试需要测量髓腔内血液流牙冠的表面温这种牙髓测试技术的原理基于一得到时间/温度对比曲线是有意 律

AssessmentofPulpVascularityVitalitytestingrequiresthemeasurementofpulpalbloodflow.Severaldevicesareusedtoevaluatecirculatorychangesratherthantheneuralintegrityofthepulp,andanumberofthesehavebeenusedexperimentallytoevaluatepulpalAninvestigatorperformedextensiveresearchinthefieldofcrownsurfacetemperature.Thispulpvitalitytechniqueisbasedonthehypothesisthatvitalteetharewarmerandwillrewarmquickeraftercoolingthannon-vitalteeth.Hisexperi-curvescomparingthewarmingofvitalversusnon-vitalteethwerediagnosticallyinformative.Attemptstousecolorchangeofcholestericliquidcrystalsasadiagnostictooltomeasurecrowntemperaturechangehavealsometwithsomesuccess.Andamorerecentstudyusinganinfraredthermographiccamerashowedcrowntemperaturepatternsofnonvitalteethtobeslowertorewarmthanthoseofvitalteeth.TransmittedTransmittedphotoplethysmography(TLP)isanoninvasivetechniqueusedtomonitorpulpalbloodflowandhasbeensuccessfullyappliedinanimalandhumanstudies.IthasbeensuggestedthatTLPincurslesssignalcontaminationfromtheperiodontalbloodflowthanisthecaseforlaserdopplerflowmetryTransmitted为光学体积描记术（TLP）认光学体积描记术（TLP） 激光血流仪LDF产生632.8nm波长的氦氖激光束，这个波长