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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