treatment of pulpal and periapical diseases. 1. case selection and treatment planning...
TRANSCRIPT
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Treatment of Pulpal and Periapical Diseases
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1. Case Selection
and Treatment Planning
病例选择与治疗计划
Pathways of the pulp, 8th edition
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Chapter Outline
• Common medical findings that may influence endodontics
• Dental evaluation
• Treatment planning
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1.1 Common medical findings that may influence endodo
ntics
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1.1.1 Pregnancy
• Not a contradiction to endodontics
• Modified treatment plan– Defer elective dental treatment during the firs
t trimester except emergency treatment– Provide routine dental care during the second tr
imester – Consult physician if necessary
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1.1.2 Cardiovascular disease
• Medically compromised patientsMedically compromised patients
• Consult with physicians before initiation of Consult with physicians before initiation of treatmenttreatment
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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
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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
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Coronary artery bypass graftCoronary artery bypass graft
• Antibiotic prophylaxis is not needed after Antibiotic prophylaxis is not needed after the first few months of recoverythe first few months of recovery
• Consultation is advisedConsultation is advised
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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
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1.1.4 AIDS
• Infection control
• Asymptomatic patients are usually candidates for endodontic treatment
• Medical consultation before endodontic surgery for HIV-infected patients
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1.1.5 Diabetes • Well controlled patients are candidates for endod
ontic 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
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1.1.6 Dialysis 透 析
• Bleeding tendency
• Elective endodontic treatment should be postponed
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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
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1.1.8 Behavioral and psychiatric disorders
Consultation before using
• Sedatives 镇静剂• Hypnotics 催眠药• Antihistamines 抗组胺药
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1.2 Dental evaluation
• Periodontal considerations
• Restorative considerations
• Endodontic considerations
• Surgical considerations
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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)
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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
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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
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1.2.4 Surgical considerations
• Of particular value in the diagnosis of nonodontogenic lesions
• Biopsy prior to definitive endodontic treatment
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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
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Treatment planning
• Treatment or extraction?• What kind of treatment ?
– Endodontic– Periodontal– Restorative
• Who will be the operator? • Single-visit or multi-visit?• Cost• Prognosis
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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
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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
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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
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Universal precautions
• American Dental Association (ADA) recommendation
• Each patient is considered potentially infectious
• The same strict infection control policies applied to all patients
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Infection control guidelines• Dental personnel vaccinated against hepatitis BDental personnel vaccinated against hepatitis B• Thorough and updated patient medical historyThorough and updated patient medical history • Proper barrier techniques for dental personnel Proper barrier techniques for dental personnel
– Masks, protective eyewear, Masks, protective eyewear, disposable latex gldisposable latex glovesoves
– Hands, wrists and lower forearms washed with Hands, wrists and lower forearms washed with soapsoap
– Use of vacuum suctionUse of vacuum suction (high-volume evacuati (high-volume evacuation) for high-speed handpiece, water spray or ulton) for high-speed handpiece, water spray or ultrasonicsrasonics
– Use of rubber damUse of rubber dam
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Cross-contamination related with handpieces
• Surface contamination 表面污染• Air contamination 空气污染• Suction contamination 回吸污染
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Rubber DamRubber Dam橡皮障橡皮障
Rubber DamRubber Dam橡皮障橡皮障
Routine placement of the rubber dam is considered the standard of care in USA
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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 foggi
ng)– Minimize patient conversation– Minimize the need for frequent rinsing
• Reduced risk of cross-contamination • Legal considerations
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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
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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
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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: ____________
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2.3 Pain control
• Local anesthesia
• Divitalization 失活法
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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 (vita
l tissue may exists periapically)– Patient’s sense aids the clinician to determine workin
g length 根管工作长度– LA is unnecessary during obturation phase (obturatio
n pressure and extrusion of sealer may produce pain)
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local anesthetics
Lidocaine 利多卡因Articaine 阿替卡因
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碧兰麻( 阿替卡因 )
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Techniques
• Conventional techniques– Supraperiosteal injection (local infiltration)– Regional nerve block
• Supplemental techniques– Periodontal ligament (PDL) injection– Intrapulpal injection– Intraseptal injection– Intraosseous (IO) injection
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• Maxillary posterior teeth– Posterior superior alveolar (PSA) block for mola
rs– Buccal infiltration for premolars– Palatal infiltration for rubber dam retainer (optio
nal)
• Maxillary anterior teeth– Labial infiltration– Palatal anesthsia for rubber dam retainer (optiona
l)
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• 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
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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
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• 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)
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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
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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
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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
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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
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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
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操作步骤• 告知患者:选择失活剂、按时复诊告知患者:选择失活剂、按时复诊• 暴露牙髓:不强调彻底去腐暴露牙髓: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:小球钻大小放置失活剂:小球钻大小 ++ 丁香油棉球丁香油棉球• ZOEZOE 暂封窝洞暂封窝洞
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失活法– 增加就诊次数– 牙体变色
适用于后牙– 失活不全
麻醉法– 缩短疗程– 适用于全口牙– 作用迅速完全
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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
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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
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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
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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 le
sions is still controversial
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Procedures1. 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. Base4. Temporary or permanent restoration
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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
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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
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Hemostatic reagents止血剂
• Saline 盐水• Hydrogen peroxide 双氧水• Diluted sodium hypochlorite 次氯酸钠• Chlorhexidine 洗必泰
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Pulp capping materials
• Calcium hydroxide
• Mineral trioxide aggregates (MTA)
矿化三氧化聚合物
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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
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3.3 pulpotomy
Indication:Immature permanent teeth
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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
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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 o
r impossible
• Internal resorption
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Conclusions
• The vital pulp therapies are predictable in teeth with tra
umatic or mechanical pulp exposure.• Direct pulp capping is contraindicated for teeth wit
h carious pulp exposure. Pulpotomy might be the ch
oice but is considered unproven.• When – for financial or other reasons – extraction is th
e only alternative, pulpotomy certainly should be consi
dered for the benefit of the patient.
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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
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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
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Pulpectomy•Complete removal of the vital pulp tissue followed by cleaning , shaping and filling of the root canal(s).
•Indicated for tooth with pulpitis
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• 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
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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
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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
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4.3 Pulp necrosis with AAP
• Without swelling
• With localized swelling
• With diffuse swelling
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Without swelling
• Thorough removal of necrotic pulp
• Complete C/S of the root canal– Introducing a small file (#10/15) slightly beyond th
e apex to establish drainage from the periapical tissues
• Ca(OH)2 dressing between visits to help eliminate remaining bacteria
• Oral analgesics
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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 a
nd drainage, I&D)– Antibiotic treatment
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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
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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 rin
ses or CHX mouth rinse
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Diffuse 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 (2~3 days)
– Referral to oral surgeons
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Antibiotic therapy
• Indicated for patients with– Diffuse swelling regardless of the establish of d
rainage– Spreading infections or systemic signs
• Penicillin (1st choice) or clindamycin or erythromycin + Metronidazole
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Endodontic Emergency TreatmentDiagnosis and Symptoms Treatment Postop MedIrreversible pulpitis
Without AAP Complete C/S NSAIDscorticosteroids
With AAP Complete C/SCa(OH)2 dressing
NSAIDscorticosteroids
Pulpal necrosis
without swelling Complete C/SCa(OH)2 dressing
NSAIDs
With localized swelling Complete C/S
Ca(OH)2 dressingI&D
NSAIDs
With diffuse swelling Complete C/S
Ca(OH)2 dressingI&D
NSAIDsantibiotics