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 <ul><li>Common medical findings that may influence endodontics </li></ul><ul><li>Dental evaluation </li></...
1.1 Common medical findings that may influence endodontics
1.1.1 Pregnancy <ul><li>Not a contradiction to endodontics </li></ul><ul><li>Modified treatment plan </li></ul><ul><ul><li...
1.1.2 Cardiovascular disease <ul><li>Medically compromised patients </li></ul><ul><li>Consult with physicians before initi...
<ul><li>Myocardial infarction  心肌梗死 </li></ul><ul><li>(heart attack) within past 6 months </li></ul><ul><li>Increased susc...
<ul><li>Patients with a history of  </li></ul><ul><ul><li>Heart murmur  心脏杂音 </li></ul></ul><ul><ul><li>Mitral valve prola...
<ul><li>Coronary artery bypass graft </li></ul><ul><li>Antibiotic prophylaxis is not needed after the first few months of ...
1.1.3 Cancer  <ul><li>Patients undergoing chemotherapy and/or  </li></ul><ul><li>radiation to the head and neck </li></ul>...
1.1.4 AIDS <ul><li>Infection control </li></ul><ul><li>Asymptomatic patients are usually candidates for endodontic treatme...
1.1.5 Diabetes  <ul><li>Well controlled patients are candidates for endodontic treatment </li></ul><ul><li>Medical consult...
1.1.6 Dialysis   透 析  <ul><li>Bleeding tendency </li></ul><ul><li>Elective endodontic treatment should be postponed </li><...
1.1.7 Prosthetic implants <ul><ul><li>Heart valves </li></ul></ul><ul><ul><li>Vascular grafts </li></ul></ul><ul><ul><li>P...
1.1.8 Behavioral and psychiatric disorders <ul><li>Consultation before using </li></ul><ul><li>Sedatives 镇静剂 </li></ul><ul...
1.2  Dental evaluation <ul><li>Periodontal considerations </li></ul><ul><li>Restorative considerations </li></ul><ul><li>E...
1.2.1 Periodontal considerations <ul><li>Periodontal probing </li></ul><ul><li>Mobility assessment </li></ul><ul><li>Radio...
1.2.2 Restorative considerations <ul><li>Restorative treatment planning before starting endodontic treatment in a nonemerg...
1.2.3 Endodontic considerations <ul><ul><li>Anatomy of roots and canals </li></ul></ul><ul><ul><li>Procedural errors </li>...
1.2.4 Surgical considerations <ul><li>Of particular value in the diagnosis of nonodontogenic lesions </li></ul><ul><li>Bio...
 
1.3 Treatment planning <ul><li>Scope of endodontics </li></ul><ul><li>Vital pulp therapy  活髓保存 </li></ul><ul><li>Pulpectom...
Treatment planning <ul><li>Treatment or extraction? </li></ul><ul><li>What kind of treatment ? </li></ul><ul><ul><li>Endod...
2. Preparation for treatment <ul><li>Infection control  </li></ul><ul><ul><li>Universal precautions </li></ul></ul><ul><ul...
2.1 Infection Control <ul><li>Dental personnel are at risk of exposure to a host of infectious organisms </li></ul><ul><li...
<ul><li>Effective infection control procedures   </li></ul><ul><li>Reduce the number of micro-organisms in the working env...
Universal precautions <ul><li>American Dental Association (ADA) recommendation </li></ul><ul><li>Each patient is considere...
Infection control guidelines <ul><li>Dental personnel vaccinated against hepatitis B </li></ul><ul><li>Thorough and update...
<ul><li>Cross-contamination related with handpieces </li></ul><ul><li>Surface contamination  表面污染 </li></ul><ul><li>Air co...
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 <ul><li>Protection </li></ul><ul><ul><li>aspiration or swallowing of instruments or irrigant...
Components of rubber dam system  <ul><li>Rubber dam (sheet)  橡皮障 </li></ul><ul><li>Frame  橡皮障架 </li></ul><ul><li>Retainers...
2.2 Informed consent <ul><li>Continuous rise in dental litigation </li></ul><ul><li>For consent to be informed </li></ul><...
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 /...
2.3 Pain control <ul><li>Local anesthesia </li></ul><ul><li>Divitalization  失活法 </li></ul>
2.3.1 Local anesthesia (LA) <ul><li>When to anesthetize </li></ul><ul><ul><li>LA should be given at each appointment </li>...
local anesthetics <ul><li>Lidocaine  利多卡因 </li></ul><ul><li>Articaine  阿替卡因 </li></ul>
碧兰麻 ( 阿替卡因 )
Techniques <ul><li>Conventional techniques </li></ul><ul><ul><li>Supraperiosteal injection (local infiltration) </li></ul>...
<ul><li>Maxillary posterior teeth </li></ul><ul><ul><li>Posterior superior alveolar (PSA) block for molars </li></ul></ul>...
<ul><li>Mandibular teeth </li></ul><ul><ul><li>Inferior alveolar nerve (IAN) block for anterior and posterior teeth </li><...
Periodontal ligment (PDL) injection <ul><li>27-gauge/short or 30-gauge/ultrashort needle </li></ul><ul><li>Placed into the...
<ul><li>Index of successful PDL injection </li></ul><ul><ul><li>Presence of resistance to anesthetic deposition </li></ul>...
Intrapulpal injection <ul><li>27-gauge/short needle </li></ul><ul><li>Inserted into the pulp chamber or canal </li></ul><u...
2.3.2  失活法   Devitalization <ul><ul><li>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 </li></ul></ul><ul><ul><li>使牙髓失活的药物称为失活剂...
<ul><li>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 </li></ul>
常用失活剂 <ul><li>多聚甲醛 </li></ul><ul><li>(三聚甲醛,简称“三甲”) </li></ul><ul><ul><li>引起牙髓血运障碍而发生坏死 </li></ul></ul><ul><ul><li>毒性弱于亚砷酸较...
常用失活剂 <ul><li>亚砷酸( As 2 O 3 ) </li></ul><ul><ul><li>毒性强:细胞原生质、神经、血管 </li></ul></ul><ul><ul><li>作用迅速:牙髓血运的影响 </li></ul></ul...
操作步骤 <ul><li>告知患者:选择失活剂、按时复诊 </li></ul><ul><li>暴露牙髓:不强调彻底去腐 </li></ul><ul><li>减压引流、控制出血:酚、肾上腺素棉球 </li></ul><ul><li>放置失活剂:小...
<ul><li>失活法 </li></ul><ul><ul><li>增加就诊次数 </li></ul></ul><ul><ul><li>牙体变色 </li></ul></ul><ul><ul><li>适用于后牙 </li></ul></ul><...
3. Vital Pulp Therapy 活髓保存治疗 <ul><li>Indirect pulp capping  间接盖髓术 </li></ul><ul><li>Direct pulp capping  直接盖髓术 </li></ul><...
3.1 Indirect pulp capping <ul><li>Indications </li></ul><ul><ul><li>deep carious lesions </li></ul></ul><ul><ul><li>No his...
Pulp Capping Materials <ul><li>Calcium hydroxide  氢氧化钙 </li></ul><ul><li>The most commonly-used  </li></ul><ul><li>(direct...
<ul><li>Zinc oxide-eugenol cement (ZnOE) </li></ul><ul><li>Only for indirect pulp capping </li></ul><ul><li>Bactericidal e...
Procedures <ul><li>1. Remove all softened, mushy or leathery dentine </li></ul><ul><li>2. Either ZOE or Ca(OH) 2  placed o...
3.2 Direct pulp capping <ul><li>Indications: </li></ul><ul><li>Accidental or mechanical pulp exposure (normal pulp) </li><...
<ul><li>Should mature teeth be pulp capped? </li></ul><ul><li>Size of exposure limited to 1mm </li></ul><ul><li>Contraindi...
Hemostatic reagents 止血剂 <ul><li>Saline  盐水 </li></ul><ul><li>Hydrogen peroxide  双氧水 </li></ul><ul><li>Diluted sodium hypoc...
Pulp capping materials <ul><li>Calcium hydroxide </li></ul><ul><li>Mineral trioxide aggregates (MTA) </li></ul><ul><li>矿化三...
Procedures <ul><li>Ca(OH) 2  applied to the exposure to stimulate differentiation of new odontoblast-like cells and format...
3.3 pulpotomy <ul><li>Indication: </li></ul><ul><li>Immature permanent teeth </li></ul>
Procedures  <ul><li>Removal of all carious dentin and pulp tissue to the level of the radicular pulp </li></ul><ul><li>Vit...
Potential problems with pulpotomy  as a permanent treatment <ul><li>Impossible to determine whether all disease tissue has...
Conclusions <ul><li>The vital pulp therapies are predictable in teeth with traumatic or mechanical pulp exposure. </li></u...
4. Emergency Treatment <ul><li>Pretreatment emergency </li></ul><ul><li>Irreversible pulpitis without acute apical periodo...
4.1 Irreversible pulpitis without AAP <ul><li>Principles: </li></ul><ul><li>Complete pulp removal </li></ul><ul><li>Total ...
<ul><li>Pulpectomy </li></ul><ul><li>Complete removal of the vital pulp tissue followed by cleaning ,  shaping and filling...
<ul><li>Multirooted teeth at the emergency visit </li></ul><ul><ul><li>Pulpotomy (removal of the coronal pulp) or patial p...
Procedure <ul><li>C/S of the root canal system  </li></ul><ul><li>A dry cotton pellet placed in the pulp chamber </li></ul...
4.2 Irreversible pulpitis with AAP <ul><li>Combination of pulpal and periapical symptoms </li></ul><ul><li>Complete pulp r...
4.3 Pulp necrosis with AAP <ul><li>Without swelling </li></ul><ul><li>With localized swelling </li></ul><ul><li>With diffu...
Without swelling <ul><li>Thorough removal of necrotic pulp </li></ul><ul><li>Complete C/S of the root canal </li></ul><ul>...
With swelling <ul><li>Principle:  </li></ul><ul><li>debridement 清理  and drainage </li></ul><ul><li>Three ways to resolve s...
Localized swelling <ul><li>Firstly try to establish drainage from root canals   </li></ul><ul><li>C/S of the root canal </...
<ul><li>Incision and drainage </li></ul><ul><li>Indicated for localized fluctuant soft tissue swelling </li></ul><ul><li>P...
Diffuse swelling <ul><li>Possible to turn into a medical emergency and life-threatening condition </li></ul><ul><li>Princi...
Antibiotic therapy <ul><li>Indicated for patients with </li></ul><ul><ul><li>Diffuse swelling regardless of the establish ...
Endodontic Emergency Treatment NSAIDs antibiotics Complete C/S Ca(OH) 2  dressing I&D With diffuse swelling NSAIDs Complet...
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Case selection and treatment planning

  1. 1. Treatment of Pulpal and Periapical Diseases
  2. 2. 1. Case Selection and Treatment Planning 病例选择与治疗计划 Pathways of the pulp, 8 th edition
  3. 3. Chapter Outline <ul><li>Common medical findings that may influence endodontics </li></ul><ul><li>Dental evaluation </li></ul><ul><li>Treatment planning </li></ul>
  4. 4. 1.1 Common medical findings that may influence endodontics
  5. 5. 1.1.1 Pregnancy <ul><li>Not a contradiction to endodontics </li></ul><ul><li>Modified treatment plan </li></ul><ul><ul><li>Defer elective dental treatment during the first trimester except emergency treatment </li></ul></ul><ul><ul><li>Provide routine dental care during the second trimester </li></ul></ul><ul><ul><li>Consult physician if necessary </li></ul></ul>
  6. 6. 1.1.2 Cardiovascular disease <ul><li>Medically compromised patients </li></ul><ul><li>Consult with physicians before initiation of treatment </li></ul>
  7. 7. <ul><li>Myocardial infarction 心肌梗死 </li></ul><ul><li>(heart attack) within past 6 months </li></ul><ul><li>Increased susceptibility to repeat infarctions and other cardiovascular complications </li></ul><ul><li>Contraindication to any elective dental care </li></ul>
  8. 8. <ul><li>Patients with a history of </li></ul><ul><ul><li>Heart murmur 心脏杂音 </li></ul></ul><ul><ul><li>Mitral valve prolapse with regurgitation 二尖瓣回流 </li></ul></ul><ul><ul><li>Rheumatic fever 风心病 </li></ul></ul><ul><ul><li>Congenital heart defect 先心病 </li></ul></ul><ul><ul><li>Artificial heart valves 人工瓣膜 </li></ul></ul><ul><li>Increased susceptibility to infective (bacterial) endocarditis 细菌性心内膜炎 </li></ul><ul><li>Potentially fatal complication </li></ul><ul><li>Prophylactic antibiotic therapy </li></ul><ul><li>预防性使用抗生素 </li></ul>
  9. 9. <ul><li>Coronary artery bypass graft </li></ul><ul><li>Antibiotic prophylaxis is not needed after the first few months of recovery </li></ul><ul><li>Consultation is advised </li></ul>
  10. 10. 1.1.3 Cancer <ul><li>Patients undergoing chemotherapy and/or </li></ul><ul><li>radiation to the head and neck </li></ul><ul><li>Impaired healing responses </li></ul><ul><li>Consult the patient’s physician before initiation of treatment </li></ul>
  11. 11. 1.1.4 AIDS <ul><li>Infection control </li></ul><ul><li>Asymptomatic patients are usually candidates for endodontic treatment </li></ul><ul><li>Medical consultation before endodontic surgery for HIV-infected patients </li></ul>
  12. 12. 1.1.5 Diabetes <ul><li>Well controlled patients are candidates for endodontic treatment </li></ul><ul><li>Medical consultation for patients with serious complications or before endodontic surgery </li></ul><ul><ul><li>Renal disease </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Coronary atherosclerotic disease </li></ul></ul><ul><ul><li>冠状动脉粥样硬化 </li></ul></ul>
  13. 13. 1.1.6 Dialysis 透 析 <ul><li>Bleeding tendency </li></ul><ul><li>Elective endodontic treatment should be postponed </li></ul>
  14. 14. 1.1.7 Prosthetic implants <ul><ul><li>Heart valves </li></ul></ul><ul><ul><li>Vascular grafts </li></ul></ul><ul><ul><li>Pacemakers 起搏器 </li></ul></ul><ul><ul><li>Cerebrospinal fluid shunts </li></ul></ul><ul><ul><li>Prosthetic joints 人工关节 </li></ul></ul><ul><li>Antibiotic prophylaxis to prevent infection at the site of the prosthesis </li></ul><ul><li>Medical consultation highly recommended </li></ul>
  15. 15. 1.1.8 Behavioral and psychiatric disorders <ul><li>Consultation before using </li></ul><ul><li>Sedatives 镇静剂 </li></ul><ul><li>Hypnotics 催眠药 </li></ul><ul><li>Antihistamines 抗组胺药 </li></ul>
  16. 16. 1.2 Dental evaluation <ul><li>Periodontal considerations </li></ul><ul><li>Restorative considerations </li></ul><ul><li>Endodontic considerations </li></ul><ul><li>Surgical considerations </li></ul>
  17. 17. 1.2.1 Periodontal considerations <ul><li>Periodontal probing </li></ul><ul><li>Mobility assessment </li></ul><ul><li>Radiographic assessment </li></ul><ul><li>Endodontic treatment should not be planned for teeth with poor periodontal prognosis (e.g. mobility III) </li></ul>
  18. 18. 1.2.2 Restorative considerations <ul><li>Restorative treatment planning before starting endodontic treatment in a nonemergency situation </li></ul><ul><ul><li>Extensive loss of tooth structure </li></ul></ul><ul><ul><li>Subosseous root caries (crown lengthening may be needed) </li></ul></ul><ul><ul><li>Poor crown-root ratio </li></ul></ul><ul><ul><li>Lack of ferrule effect </li></ul></ul><ul><ul><li>Misaligned tooth </li></ul></ul><ul><li>Consultation with a prosthodontist </li></ul>
  19. 19. 1.2.3 Endodontic considerations <ul><ul><li>Anatomy of roots and canals </li></ul></ul><ul><ul><li>Procedural errors </li></ul></ul><ul><ul><li>Small mouth </li></ul></ul><ul><ul><li>Instruments </li></ul></ul><ul><ul><li>Operator skill </li></ul></ul><ul><ul><li>Time </li></ul></ul><ul><li>To determine the level of anticipated difficulty </li></ul><ul><li>To identify cases that should be referred </li></ul>
  20. 20. 1.2.4 Surgical considerations <ul><li>Of particular value in the diagnosis of nonodontogenic lesions </li></ul><ul><li>Biopsy prior to definitive endodontic treatment </li></ul>
  21. 22. 1.3 Treatment planning <ul><li>Scope of endodontics </li></ul><ul><li>Vital pulp therapy 活髓保存 </li></ul><ul><li>Pulpectomy or RCT 牙髓摘除术或根管治疗 </li></ul><ul><li>Endodontic surgery 牙髓外科 </li></ul><ul><li>Retreatment 再处理 </li></ul><ul><li>Hemisection or root amputation 牙半切或截根术 </li></ul><ul><li>Bleaching 牙漂白 </li></ul><ul><li>Apexification or apexogenesis </li></ul><ul><li>根尖发育成形术或根尖诱导术 </li></ul>
  22. 23. Treatment planning <ul><li>Treatment or extraction? </li></ul><ul><li>What kind of treatment ? </li></ul><ul><ul><li>Endodontic </li></ul></ul><ul><ul><li>Periodontal </li></ul></ul><ul><ul><li>Restorative </li></ul></ul><ul><li>Who will be the operator? </li></ul><ul><li>Single-visit or multi-visit? </li></ul><ul><li>Cost </li></ul><ul><li>Prognosis </li></ul>
  23. 24. 2. Preparation for treatment <ul><li>Infection control </li></ul><ul><ul><li>Universal precautions </li></ul></ul><ul><ul><li> (operatory preparation) </li></ul></ul><ul><ul><li>Instrument sterilization </li></ul></ul><ul><ul><li>Tooth isolation 患牙隔离 </li></ul></ul><ul><li>Patient preparation </li></ul><ul><ul><li>Informed consent 知情同意 </li></ul></ul><ul><ul><li>Pain control </li></ul></ul>
  24. 25. 2.1 Infection Control <ul><li>Dental personnel are at risk of exposure to a host of infectious organisms </li></ul><ul><li>Risk of cross-contamination in the dental environment </li></ul>
  25. 26. <ul><li>Effective infection control procedures </li></ul><ul><li>Reduce the number of micro-organisms in the working environment </li></ul><ul><li>Protect patients and the dental team </li></ul><ul><li>Improve the outcome of endodontic treatment </li></ul>
  26. 27. Universal precautions <ul><li>American Dental Association (ADA) recommendation </li></ul><ul><li>Each patient is considered potentially infectious </li></ul><ul><li>The same strict infection control policies applied to all patients </li></ul>
  27. 28. Infection control guidelines <ul><li>Dental personnel vaccinated against hepatitis B </li></ul><ul><li>Thorough and updated patient medical history </li></ul><ul><li>Proper barrier techniques for dental personnel </li></ul><ul><ul><li>Masks, protective eyewear, disposable latex gloves </li></ul></ul><ul><ul><li>Hands, wrists and lower forearms washed with soap </li></ul></ul><ul><ul><li>Use of vacuum suction (high-volume evacuation) for high-speed handpiece, water spray or ultrasonics </li></ul></ul><ul><ul><li>Use of rubber dam </li></ul></ul>
  28. 29. <ul><li>Cross-contamination related with handpieces </li></ul><ul><li>Surface contamination 表面污染 </li></ul><ul><li>Air contamination 空气污染 </li></ul><ul><li>Suction contamination 回吸污染 </li></ul>
  29. 30. Rubber Dam 橡皮障 Routine placement of the rubber dam is considered the standard of care in USA
  30. 31. Reasons for use of rubber dam <ul><li>Protection </li></ul><ul><ul><li>aspiration or swallowing of instruments or irrigants </li></ul></ul><ul><ul><li>Soft tissue injury caused by instruments </li></ul></ul><ul><li>Efficiency </li></ul><ul><ul><li>Improve visibility (dry field and reduced mirror fogging) </li></ul></ul><ul><ul><li>Minimize patient conversation </li></ul></ul><ul><ul><li>Minimize the need for frequent rinsing </li></ul></ul><ul><li>Reduced risk of cross-contamination </li></ul><ul><li>Legal considerations </li></ul>
  31. 32. Components of rubber dam system <ul><li>Rubber dam (sheet) 橡皮障 </li></ul><ul><li>Frame 橡皮障架 </li></ul><ul><li>Retainers (clamps) 橡皮障夹 </li></ul><ul><li>Punch 橡皮障打孔器 </li></ul><ul><li>Forceps 橡皮障钳 </li></ul>
  32. 33. 2.2 Informed consent <ul><li>Continuous rise in dental litigation </li></ul><ul><li>For consent to be informed </li></ul><ul><ul><li>The procedure and prognosis must be described </li></ul></ul><ul><ul><li>Alternatives to the recommended treatment must be presented along with their respective prognoses </li></ul></ul><ul><ul><li>Foreseeable risks must be described </li></ul></ul><ul><ul><li>Patients must have the opportunity to have questions answered </li></ul></ul>
  33. 34. 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: ____________
  34. 35. 2.3 Pain control <ul><li>Local anesthesia </li></ul><ul><li>Divitalization 失活法 </li></ul>
  35. 36. 2.3.1 Local anesthesia (LA) <ul><li>When to anesthetize </li></ul><ul><ul><li>LA should be given at each appointment </li></ul></ul><ul><li>Three misconceptions </li></ul><ul><ul><li>Necrotic teeth may be instrumented without LA (vital tissue may exists periapically) </li></ul></ul><ul><ul><li>Patient’s sense aids the clinician to determine working length 根管工作长度 </li></ul></ul><ul><ul><li>LA is unnecessary during obturation phase (obturation pressure and extrusion of sealer may produce pain) </li></ul></ul>
  36. 37. local anesthetics <ul><li>Lidocaine 利多卡因 </li></ul><ul><li>Articaine 阿替卡因 </li></ul>
  37. 38. 碧兰麻 ( 阿替卡因 )
  38. 39. Techniques <ul><li>Conventional techniques </li></ul><ul><ul><li>Supraperiosteal injection (local infiltration) </li></ul></ul><ul><ul><li>Regional nerve block </li></ul></ul><ul><li>Supplemental techniques </li></ul><ul><ul><li>Periodontal ligament (PDL) injection </li></ul></ul><ul><ul><li>Intrapulpal injection </li></ul></ul><ul><ul><li>Intraseptal injection </li></ul></ul><ul><ul><li>Intraosseous (IO) injection </li></ul></ul>
  39. 40. <ul><li>Maxillary posterior teeth </li></ul><ul><ul><li>Posterior superior alveolar (PSA) block for molars </li></ul></ul><ul><ul><li>Buccal infiltration for premolars </li></ul></ul><ul><ul><li>Palatal infiltration for rubber dam retainer (optional) </li></ul></ul><ul><li>Maxillary anterior teeth </li></ul><ul><ul><li>Labial infiltration </li></ul></ul><ul><ul><li>Palatal anesthsia for rubber dam retainer (optional) </li></ul></ul>
  40. 41. <ul><li>Mandibular teeth </li></ul><ul><ul><li>Inferior alveolar nerve (IAN) block for anterior and posterior teeth </li></ul></ul><ul><ul><li>Incisive nerve block for premolars and anterior teeth </li></ul></ul><ul><ul><li>Labial infiltration for anterior teeth </li></ul></ul>
  41. 42. Periodontal ligment (PDL) injection <ul><li>27-gauge/short or 30-gauge/ultrashort needle </li></ul><ul><li>Placed into the periodontal space between the root and the interseptal bone </li></ul><ul><li>Bevel facing the root </li></ul><ul><li>0.2mL of anesthetic slowly deposited on the distal of each root of the tooth </li></ul>
  42. 43. <ul><li>Index of successful PDL injection </li></ul><ul><ul><li>Presence of resistance to anesthetic deposition </li></ul></ul><ul><ul><li>Ischemia of the soft tissue at the site of injection </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Presence of infection or inflammation in the area </li></ul></ul><ul><ul><li>of needle insertion (e.g. acute apical abscess) </li></ul></ul>
  43. 44. Intrapulpal injection <ul><li>27-gauge/short needle </li></ul><ul><li>Inserted into the pulp chamber or canal </li></ul><ul><li>Resistance met and 0.2~0.3mL of the solution expressed </li></ul><ul><li>In lack of a snug fit of the needle </li></ul><ul><ul><li>warm gutta percha 牙胶 inserted around the needle </li></ul></ul><ul><ul><li>Injection under pressure after cooling </li></ul></ul>
  44. 45. 2.3.2 失活法 Devitalization <ul><ul><li>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 </li></ul></ul><ul><ul><li>使牙髓失活的药物称为失活剂 </li></ul></ul>
  45. 46. <ul><li>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 </li></ul>
  46. 47. 常用失活剂 <ul><li>多聚甲醛 </li></ul><ul><li>(三聚甲醛,简称“三甲”) </li></ul><ul><ul><li>引起牙髓血运障碍而发生坏死 </li></ul></ul><ul><ul><li>毒性弱于亚砷酸较安全 </li></ul></ul><ul><ul><li>作用相对缓慢 </li></ul></ul><ul><ul><li>封药时间:全牙髓 14 天 </li></ul></ul><ul><ul><li>根髓 7-10 天 </li></ul></ul>
  47. 48. 常用失活剂 <ul><li>亚砷酸( As 2 O 3 ) </li></ul><ul><ul><li>毒性强:细胞原生质、神经、血管 </li></ul></ul><ul><ul><li>作用迅速:牙髓血运的影响 </li></ul></ul><ul><ul><li>无自限性:化学性根尖周炎 </li></ul></ul><ul><ul><li>严格控制封药时间: 24-48 小时 </li></ul></ul><ul><ul><li>禁用于根尖孔未形成的患牙 </li></ul></ul>
  48. 49. 操作步骤 <ul><li>告知患者:选择失活剂、按时复诊 </li></ul><ul><li>暴露牙髓:不强调彻底去腐 </li></ul><ul><li>减压引流、控制出血:酚、肾上腺素棉球 </li></ul><ul><li>放置失活剂:小球钻大小 + 丁香油棉球 </li></ul><ul><li>ZOE 暂封窝洞 </li></ul>
  49. 50. <ul><li>失活法 </li></ul><ul><ul><li>增加就诊次数 </li></ul></ul><ul><ul><li>牙体变色 </li></ul></ul><ul><ul><li>适用于后牙 </li></ul></ul><ul><ul><li>失活不全 </li></ul></ul><ul><li>麻醉法 </li></ul><ul><ul><li>缩短疗程 </li></ul></ul><ul><ul><li>适用于全口牙 </li></ul></ul><ul><ul><li>作用迅速完全 </li></ul></ul>
  50. 51. 3. Vital Pulp Therapy 活髓保存治疗 <ul><li>Indirect pulp capping 间接盖髓术 </li></ul><ul><li>Direct pulp capping 直接盖髓术 </li></ul><ul><li>Pulpotomy 牙髓切断术 </li></ul><ul><li>“ Principles and practice of endodontics” </li></ul><ul><li>2th edition </li></ul>
  51. 52. 3.1 Indirect pulp capping <ul><li>Indications </li></ul><ul><ul><li>deep carious lesions </li></ul></ul><ul><ul><li>No history of pulpalgia </li></ul></ul><ul><ul><li>No signs of irreversible pulpitis </li></ul></ul><ul><ul><li>No pulp exposure </li></ul></ul><ul><ul><li>after excavation of carious dentine </li></ul></ul>
  52. 53. Pulp Capping Materials <ul><li>Calcium hydroxide 氢氧化钙 </li></ul><ul><li>The most commonly-used </li></ul><ul><li>(direct) pulp-capping material </li></ul><ul><ul><li>Water-based calcium hydroxide </li></ul></ul><ul><ul><li>Resin-based Calcium hydroxide </li></ul></ul><ul><ul><li>e.g. Dycal, Timeline </li></ul></ul>
  53. 54. <ul><li>Zinc oxide-eugenol cement (ZnOE) </li></ul><ul><li>Only for indirect pulp capping </li></ul><ul><li>Bactericidal effect and hermetic marginal seal </li></ul><ul><li>Cytotoxicity-use of ZnOE as a liner in deep carious lesions is still controversial </li></ul>
  54. 55. Procedures <ul><li>1. Remove all softened, mushy or leathery dentine </li></ul><ul><li>2. Either ZOE or Ca(OH) 2 placed on the remaining dentin to kill or suppress bacteria </li></ul><ul><li>3. Base </li></ul><ul><li>4. Temporary or permanent restoration </li></ul>
  55. 56. 3.2 Direct pulp capping <ul><li>Indications: </li></ul><ul><li>Accidental or mechanical pulp exposure (normal pulp) </li></ul><ul><ul><li>Cavity preparation </li></ul></ul><ul><ul><li>Placement of pins </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><li>Mainly for immature permanent teeth with recent (<24 hr) traumatic pulp exposure or mechanical exposure during cavity preparation </li></ul>
  56. 57. <ul><li>Should mature teeth be pulp capped? </li></ul><ul><li>Size of exposure limited to 1mm </li></ul><ul><li>Contraindicated for carious tooth with </li></ul><ul><li>pulp involvement </li></ul>Enamel-dentin fracture with pulpal involvement Direct pulp capping
  57. 58. Hemostatic reagents 止血剂 <ul><li>Saline 盐水 </li></ul><ul><li>Hydrogen peroxide 双氧水 </li></ul><ul><li>Diluted sodium hypochlorite 次氯酸钠 </li></ul><ul><li>Chlorhexidine 洗必泰 </li></ul>
  58. 59. Pulp capping materials <ul><li>Calcium hydroxide </li></ul><ul><li>Mineral trioxide aggregates (MTA) </li></ul><ul><li>矿化三氧化聚合物 </li></ul>
  59. 60. Procedures <ul><li>Ca(OH) 2 applied to the exposure to stimulate differentiation of new odontoblast-like cells and formation of secondary dentin </li></ul><ul><li>Temporary restoration placed over Ca(OH) 2 </li></ul><ul><li>Follow-up </li></ul><ul><li>Permanent restoration </li></ul><ul><li>Pulpotomy or endodontic treatment for symptomatic tooth </li></ul>
  60. 61. 3.3 pulpotomy <ul><li>Indication: </li></ul><ul><li>Immature permanent teeth </li></ul>
  61. 62. Procedures <ul><li>Removal of all carious dentin and pulp tissue to the level of the radicular pulp </li></ul><ul><li>Vital pulp stump capped with Ca(OH) 2 </li></ul><ul><li>Temporary restoration </li></ul><ul><li>Follow-up </li></ul><ul><li>Asymptomatic: permanent restoration </li></ul><ul><li>Symptomatic: endodontic treatment </li></ul>
  62. 63. Potential problems with pulpotomy as a permanent treatment <ul><li>Impossible to determine whether all disease tissue has been removed </li></ul><ul><li>The remaining radicular pulp tissue may undergo mineralization </li></ul><ul><ul><li>Making further endodontic treatment difficult or impossible </li></ul></ul><ul><li>Internal resorption </li></ul>
  63. 64. Conclusions <ul><li>The vital pulp therapies are predictable in teeth with traumatic or mechanical pulp exposure. </li></ul><ul><li>Direct pulp capping is contraindicated for teeth with carious pulp exposure. Pulpotomy might be the choice but is considered unproven. </li></ul><ul><li>When – for financial or other reasons – extraction is the only alternative, pulpotomy certainly should be considered for the benefit of the patient. </li></ul>
  64. 65. 4. Emergency Treatment <ul><li>Pretreatment emergency </li></ul><ul><li>Irreversible pulpitis without acute apical periodontitis </li></ul><ul><li>Irreversible pulpitis with acute apical periodontitis </li></ul><ul><li>Pulp necrosis with acute apical periodontitis </li></ul><ul><li>Pathways of the pulp, 8 th edition </li></ul><ul><li>Principles and practice of endodontics, 2 th edition </li></ul>
  65. 66. 4.1 Irreversible pulpitis without AAP <ul><li>Principles: </li></ul><ul><li>Complete pulp removal </li></ul><ul><li>Total cleaning and shaping (C/S) of the root canal system 根管清理和成形 </li></ul><ul><li>Pulpectomy is the best to achieve pain relief </li></ul>
  66. 67. <ul><li>Pulpectomy </li></ul><ul><li>Complete removal of the vital pulp tissue followed by cleaning , shaping and filling of the root canal(s). </li></ul><ul><li>Indicated for tooth with pulpitis </li></ul>
  67. 68. <ul><li>Multirooted teeth at the emergency visit </li></ul><ul><ul><li>Pulpotomy (removal of the coronal pulp) or patial pulpotomy (removal of the pulp from the widest canal) acceptable but less predictable in pain relief </li></ul></ul>
  68. 69. Procedure <ul><li>C/S of the root canal system </li></ul><ul><li>A dry cotton pellet placed in the pulp chamber </li></ul><ul><li>Complete caries removal and effective temporary coronal seal to prevent contamination </li></ul><ul><li>Occlusal reduction 咬合调整 </li></ul>
  69. 70. 4.2 Irreversible pulpitis with AAP <ul><li>Combination of pulpal and periapical symptoms </li></ul><ul><li>Complete pulp removal and C/S </li></ul><ul><li>Ca(OH) 2 medication in canals to prevent bacterial regrowth </li></ul><ul><li>Effective temporary coronal seal </li></ul><ul><li>Occlusal reduction </li></ul><ul><li>Oral analgesic medication when necessary </li></ul>
  70. 71. 4.3 Pulp necrosis with AAP <ul><li>Without swelling </li></ul><ul><li>With localized swelling </li></ul><ul><li>With diffuse swelling </li></ul>
  71. 72. Without swelling <ul><li>Thorough removal of necrotic pulp </li></ul><ul><li>Complete C/S of the root canal </li></ul><ul><ul><li>Introducing a small file (#10/15) slightly beyond the apex to establish drainage from the periapical tissues </li></ul></ul><ul><li>Ca(OH) 2 dressing between visits to help eliminate remaining bacteria </li></ul><ul><li>Oral analgesics </li></ul>
  72. 73. With swelling <ul><li>Principle: </li></ul><ul><li>debridement 清理 and drainage </li></ul><ul><li>Three ways to resolve swelling and infection </li></ul><ul><ul><li>Drainage through the root canal </li></ul></ul><ul><ul><li>Drainage by incising a fluctuant swelling (incision and drainage, I&D) </li></ul></ul><ul><ul><li>Antibiotic treatment </li></ul></ul>
  73. 74. Localized swelling <ul><li>Firstly try to establish drainage from root canals </li></ul><ul><li>C/S of the root canal </li></ul><ul><ul><li>Introducing a small file (size 10/15) slightly beyond the apex to establish drainage </li></ul></ul><ul><ul><li>No I&D in case of good drainage </li></ul></ul><ul><li>Ca(OH) 2 medication </li></ul><ul><li>Access seal </li></ul><ul><ul><li>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 </li></ul></ul>
  74. 75. <ul><li>Incision and drainage </li></ul><ul><li>Indicated for localized fluctuant soft tissue swelling </li></ul><ul><li>Principles </li></ul><ul><ul><li>Incise at the site of the greatest fluctuance </li></ul></ul><ul><ul><li>Dissect gently and extend to the roots </li></ul></ul><ul><ul><li>Keep wound clean with hot saltwater mouth rinses or CHX mouth rinse </li></ul></ul>
  75. 76. Diffuse swelling <ul><li>Possible to turn into a medical emergency and life-threatening condition </li></ul><ul><li>Principles </li></ul><ul><ul><li>Thorough C/S of the canals </li></ul></ul><ul><ul><li>Apical patency achieved whenever possible </li></ul></ul><ul><ul><li>Tooth left open </li></ul></ul><ul><ul><li>I&D in the absence of drainage through the canals with a rubber dam drain inserted or sutured (2~3 days) </li></ul></ul><ul><ul><li>Referral to oral surgeons </li></ul></ul>
  76. 77. Antibiotic therapy <ul><li>Indicated for patients with </li></ul><ul><ul><li>Diffuse swelling regardless of the establish of drainage </li></ul></ul><ul><ul><li>Spreading infections or systemic signs </li></ul></ul><ul><li>Penicillin (1st choice) or clindamycin or erythromycin + Metronidazole </li></ul>
  77. 78. 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

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