病例选择与治疗计划12课件.ppt
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- 病例 选择 治疗 计划 12 课件
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1、Treatment of Pulpal and Periapical Diseases1.Case Selection and Treatment Planning病例选择与治疗计划病例选择与治疗计划Pathways of the pulp,8th editionChapter Outline Common medical findings that may influence endodontics Dental evaluation Treatment planning1.1 Common medical findings that may influence endodontics1.1
2、.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 necessary1.1.2 Cardiovascular diseaseMyocardial infarction 心肌梗死心肌
3、梗死(heart attack)within past 6 months Increased susceptibility to repeat infarctions and other cardiovascular complications Contraindication to any elective dental carePatients 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 defe
4、ct 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预防性使用抗生素预防性使用抗生素1.1.3 Cancer Patients undergoing chemotherapy and/or radiation to the head and neck Impaired healing responses Consul
5、t the patients physician before initiation of treatment1.1.4 AIDS Infection control Asymptomatic patients are usually candidates for endodontic treatment Medical consultation before endodontic surgery for HIV-infected patients1.1.5 Diabetes Well controlled patients are candidates for endodontic trea
6、tment 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 透透 析析 Bleeding tendency Elective endodontic treatment should be postponed1.1.7 Prosthetic implants Heart valves Vascular g
7、rafts 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 recommended1.1.8 Behavioral and psychiatric disordersConsultation before using Sedatives镇静剂 Hypnotics催眠药 Antihistamines 抗组胺药1.2
8、Dental evaluation Periodontal considerations Restorative considerations Endodontic considerations Surgical considerations1.2.1 Periodontal considerations Periodontal probing Mobility assessment Radiographic assessment Endodontic treatment should not be planned for teeth with poor periodontal prognos
9、is(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
10、Consultation with a prosthodontist1.2.3 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 referred1.2.4 Surgical considerations Of particular value in t
11、he diagnosis of nonodontogenic lesions Biopsy prior to definitive endodontic treatment 1.3 Treatment planningScope of endodontics Vital pulp therapy 活髓保存活髓保存 Pulpectomy or RCT 牙髓摘除术或根管治疗牙髓摘除术或根管治疗 Endodontic surgery 牙髓外科牙髓外科 Retreatment 再处理再处理 Hemisection or root amputation 牙半切或截根术牙半切或截根术 Bleaching
12、牙漂白牙漂白 Apexification or apexogenesis根尖发育成形术或根尖诱导术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(o
13、peratory preparation)Instrument sterilization Tooth isolation 患牙隔离 Patient preparation Informed consent 知情同意 Pain control2.1 Infection Control Dental personnel are at risk of exposure to a host of infectious organisms Risk of cross-contamination in the dental environmentEffective infection control p
14、rocedures Reduce the number of micro-organisms in the working environment Protect patients and the dental team Improve the outcome of endodontic treatmentUniversal precautions American Dental Association(ADA)recommendation Each patient is considered potentially infectious The same strict infection c
15、ontrol policies applied to all patientsInfection control guidelinesCross-contamination related with handpieces Surface contamination 表面污染 Air contamination 空气污染 Suction contamination 回吸污染Routine placement of the rubber dam is considered the standard of care in USAReasons for use of rubber dam Protec
16、tion 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 considerationsComponent
17、s of rubber dam system Rubber dam(sheet)橡皮障橡皮障 Frame 橡皮障架橡皮障架 Retainers(clamps)橡皮障夹橡皮障夹 Punch 橡皮障打孔器橡皮障打孔器 Forceps 橡皮障钳橡皮障钳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
18、 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。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。本人因诊断为本人因诊断为_,_,同意授权同意授权_医生进行医生进行_的的根管治疗(镍钛机动预备根管治疗(镍钛机动预备/手动预备,热牙胶充填手动预备,热牙
19、胶充填/冷侧压充填)。同时我也冷侧压充填)。同时我也同意上述医生在他同意上述医生在他(她她)认为必要认为必要 (或按治疗计划认为必要或按治疗计划认为必要)的情况下照的情况下照X X线片,线片,使用药物治疗、麻醉以及相关设备或处理措施。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治
20、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。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:
21、疼痛、肿胀、牙关紧闭、感染、出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。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(镍钛机就诊医生已向我介绍了根管治疗(镍钛机动预备动预备/手动预备,热牙胶充填手动预备,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。疑问也已从就诊医生处得到满意的回答。本人同意医生采用本人同意医生采用_ _ _治疗方案,治疗方案,具体治疗费用约具体治疗费用约_元。元
22、。患者姓名:患者姓名:_ _ 时间:时间:_患者签名(若患者为未成年人则由监护人代签):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:主诊医生签名:_ _ 时间:时间:_ _ 2.3 Pain control Local anesthesia Divitalization 失活法失活法2.3.1 Local anesthesia(LA)When to anesthetize LA should be given at each appointment Three misconceptions Necrotic teeth may be instrumented withou
23、t LA(vital tissue may exists periapically)Patients 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 anestheticsLidocaine 利多卡因利多卡因Articaine 阿替卡因阿替卡因碧兰麻碧兰麻(阿替卡因阿替卡因)Techniques Conven
24、tional 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 infil
25、tration 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 anter
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