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Case+selection+and+treatment+planning Case+selection+and+treatment+planning Presentation Transcript

  • 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, 8 th 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( As 2 O 3 )
      • 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
      • 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
  • 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
    • Ca(OH) 2 applied to the exposure to stimulate differentiation of new odontoblast-like cells and formation of secondary dentin
    • Temporary restoration placed over Ca(OH) 2
    • Follow-up
    • Permanent restoration
    • 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, 8 th edition
    • Principles and practice of endodontics, 2 th 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 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
  • 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 NSAIDs antibiotics Complete C/S Ca(OH) 2 dressing I&D With diffuse swelling NSAIDs Complete C/S Ca(OH) 2 dressing I&D With localized swelling NSAIDs Complete C/S Ca(OH) 2 dressing without swelling Pulpal necrosis NSAIDs corticosteroids Complete C/S Ca(OH) 2 dressing With AAP NSAIDs corticosteroids Complete C/S Without AAP Irreversible pulpitis Postop Med Treatment Diagnosis and Symptoms